Dr. Amyn Rajani - Knee Surgeon and Shoulder Surgeon
Dr. Amyn Rajani - Knee Surgeon and Shoulder Surgeon
M.S Orth (Gold Medallist), D-Orth, MBBS
Knee and Shoulder Surgeon
(Arthroscopy & Joint Reconstruction)
Orthopaedic Arthroscopy Knee and Shoulder Clinic (OAKS) - arthroscopy surgeon

Arthroscopic ACL Reconstruction

» Do I Need Surgery? :
Treatment decisions for ACL tears are always individualized - tailored to each individual. The decision whether to offer surgery is based on the person's age, activity level, how unstable the knee is, and whether other structures in the knee have been injured.

It is important to keep in mind that surgery to reconstruct a torn ACL is not an emergency for most people. Many people with a torn ACL do not need surgery at all. Even though the chances for complete success from surgery are now excellent, surgery is not for everyone. This is because not everyone needs the ligament repaired to return to his or her pre-injury level of function. It is important to distinguish whether the work, recreational, and athletic activities of the person is light, moderate, or strenuous. Another important issue that needs to be understood by the individual considering ACL reconstruction is that it requires many weeks and months of hard work in rehabilitation following the reconstruction. This needs commitment and time.

» Surgery :
The most common autograft options are bone-patella-bone tendon and hamstrings. ACL reconstruction is typically done as an outpatient procedure. Depending on graft choice, open incisions may be necessary to harvest the tissue that is to be used as the new ACL. Knee arthroscopy is then performed to inspect the knee, treat additional injuries (meniscus tears or cartilage damage), and to prepare the knee for the new ACL.

Once the graft tissue has been prepared and the torn ACL tissue has been removed, the surgeon is ready to place the ligament within the knee. Small tunnels (7-10 mm) are drilled in the tibia and the femur to allow the ligament to be pulled up into the knee.

Accurate placement of these tunnels is critical to successful ACL surgery. After the ACL graft is in position, fixation devices (screws, washers, buttons, etc.) are used to keep it there until it can heal into its place.

» Surgical steps :
  1. The surgeon inspects the knee and removes the remains of the old ACL using an arthroscopic shaver.
  2. The graft which is used for reconstruction, is harvested and prepared for the replacement. Usually the patellar tendon or the Semitendinosis and Gracilis tendon autografts are used in athletes.
  3. After harvesting the tissue, a hole is drilled from the front of the tibia diagonally into the knee and ends up where the ACL attaches to the top of the shin. Next, the surgeon drills a hole in the femur at the anatomical foot-Print on the lateral Femoral condyle.
  4. The harvested replacement graft pulled into place through the holes which were just drilled and locked after flipping the Endo-CL Button.
  5. The new ligament is then held into place by two bio-absorbable screws or metallic screws.

Graft Harvesting

Graft Preparation

Final Fixation

Post-op x-ray

In this procedure, rather than using the patellar tendon, the surgeon uses the patient's own hamstring tendon, either the Semitendinosus and Gracilis tendons from the same leg.

There are several variations of this technique. Newer hamstring fixation techniques have been developed to match and even exceed the initial pullout strength of the patella bone tendon bone procedure. Special screws with threads designed not to cut the hamstring tendons are able to fix the tendon within the bone tunnel, as described with the patella bone tendon bone technique.

» Rehabilitation
For the first two weeks after the ACL Surgery, one will need to concentrate on regaining strength of muscles and on minimizing the amount of swelling. one should ice and elevate your knee as much as possible, and avoid spending time on your feet. You will require crutches for some period of time after your surgery. The amount of time that you spend on crutches depends on how well one is doing.

By the end of this period, ther wound wouldl have healed and one should be able to move the knee from full extension to ninety degrees of flexion. Each of these exercises should be done gently and gradually, and one should not push oneself to a point where there is a significant amount of pain.

Postoperative Rehabilitation Protocol for ACL Reconstruction

» General Guidelines :
  • This program is designed to protect the ACL and the patella and get complete extension at an early stage.
  • Keep in mind a 12 week period for graft to bone healing.
  • Flexion is restricted to 90 degrees.
Beginning of general activities of daily living :
Bath and shower : once sutures / stitches removed.
Removal of leg brace: only at night whilst sleeping.
Full weight bearing without crutches: usually by 2 weeks or as tolerated.

Schedule for physiotherapy :
Formal visits by a physiotherapist begins after removal of sutures, about 2 weeks.
This supervised therapy continues initially every alternate day and later about twice a week for about 3 months.
Patient has to continue home exercises, as instructed by the physiotherapist on a daily basis.

» Phase I :
This is the phase starts immediately after surgery till about 4 weeks. In this phase the patient performs hip, knee and ankle strengthening exercises.

During phase 1
The goals of rehabilitation in phase 1 are to protect the healing of soft tissue and bones, as wells as to mobilize the knee, so as to prevent stiffness of the joint. Walking full weight bearing with the help of walking aid is initiated in this phase.

Therapeutic Exercises
O to 2 weeks
> Hip flexion, extension, abduction and adduction as per comfort level
> Straight leg raises and static quadriceps exercises
> Ankle pumps
> Patella mobilizations
> Passive full extension

2 weeks to 4 weeks
All the above as well as the following:
> Active range of motion of knee joint with complete extension but limit flexion to 90
> After the sutures are out at 2 weeks, excercises performed under water are very helpful.

» Phase II :
Begins at 1 month after surgery, and extends to the 3 months after surgery.

Goals :
> Increasing the range of motion to full flexion.
> Continue lower extremity muscle toning.
> Begin total patient reconditioning with non-impact cardiovascular exercise.

Therapeutic Exercises :
> Begin isometric quads and co-contraction of quads / hams.
> Progress to mini-squats when one is able to be full weight bearing, graduated stepups.
> May continue hip flexion / extension / abduction / adduction.
> Closed kinetic chain for knee extension, utilizing resisted band while standing and weight machines as follows.
  • Stationary bike, stairmaster and elliptical machines can be used for cardio and leg
  • Conditioning.
  • Balance and proprioception activities (e.g. single leg stance).

  • » Phase III :
    From 3 months to 5 months postoperatively.

    Goals :
  • Restore any residual loss of motion that may prevent functional progression.
  • Improve functional strength and proprioception utilizing closed and open kinetic chain exercises.
  • Continue to work on restoration of the functional progression of the extremity and the patient as a whole in preparation for return to activity or sports.

  • Therapeutic Exercises :
    > Continue lower extremity exercise progression with emphasis on quads tone and strength.
    > Treadmill walking progress to running as tolerated.
    > Stairmaster/elliptical trainer, swimming is allowed.
    > May progress to out door biking, walking and ultimately running.
    > May play golf or bowling as per comfort level.
    > No twisting turning or jumping activities yet.

    » Phase IV :
    Return to sport at approximately 5-6 months.

    Goals :
    > Safe and gradual return to work or athletic participation.
    > Sports specific training.
    > Maintenance of strength, endurance and function.
    > Running progression.
    > Jumping (plyometrics) if needed for sport (i.e., volleyball or basketball).

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