Back in the Game: Relief from ACL Knee Reconstruction Orthopaedic and Spine Center

You’re playing hard in a basketball game, pivot to shoot and feel a pop in your knee. Later, your knee aches, swells and feels unstable. When you don’t listen to your body and hit the court again, despite the pain, your knee gives out on you. You might call it a trick knee. Likely, you’ve torn your anterior cruciate ligament (ACL)—one of the knee’s four stabilizing ligaments. Keep reading to learn more and hear about options to get back in the game.

“The typical way to tear it is a noncontact twisting injury,” says Dr. Boyd W.Haynes III of the Orthopaedic and Spine Center in Newport News. The guilty sports include basketball, soccer and football and any activity where players suddenly turn and pivot. Such injuries aren’t limited to young athletes—Haynes and others see torn ACLs in people of all ages. Golfer Tiger Woods is one of the best-known athletes to suffer a torn ACL.

“The number one problem is the knee is no longer stable,” says Dr. Samuel Robinson of the Jordan-Young Institute for Orthopedic Surgery and Sports Medicine in Virginia Beach. “You could fall down if, for example, you go back to playing soccer and put stress on the knee by changing directions quickly.”

Left alone, the ACL won’t heal itself, Robinson says.

If you’re not planning to return to the sport, you don’t necessarily need surgery—even if you’re exercising, Robinson says. “If my parents tore their ACLs, they would not need them reconstructed,” Robinson says. “A lot of professional athletes play their sports without an ACL. Offensive linemen are not changing directions a lot. But if you’re a wide receiver,you absolutely need your ACL.”

But “If you’re a 60-year-old skier and that’s what you love to do, you should have your ACL reconstructed,” Haynes says.

Continuing to play the sport that caused the injury without reconstructing the ACL can lead to more problems. “If you go back to playing sports and you don’t have an ACL, if your knee buckles on you it can cause more damage to the meniscus and cartilage,” Robinson warns.

Although you need the surgery, you’ll also need to wait until swelling is down, Haynes says.

There are several good options to create a new ACL, orthopedic surgeons say. The surgery is usually arthroscopic (with smaller incisions) and on an outpatient basis. Surgeons drill a tunnel in the bone and place a reconstructed ACL,made from your own hamstring tendon, another knee tendon or tendon from a cadaver.

Side effects can include stiffness, pain and infection.Some patients are concerned about the risk (one in a couple million) of disease transmission from a cadaver tendon and opt to use their own tissue, Haynes says, emphasizing that the risk is minimal because tissue banks carefully check such tissue before using it. Using the patient’s own tendon usually leads to more pain and swelling and a longer rehab, he says. Long-term results are about the same, he says.

As some ACL reconstruction patients have developed arthritis in their knees and have required knee replacement surgery earlier, surgeons have continued to look for ways to further improve ACL surgery, Robinson says. New high resolution CT scans now enable doctors to see the body’s landmarks, indicating exactly where the old ACL was and to put the reconstructed ACL in the exact location as the old ACL, Robinson says. “We’ve found it’s critically important where the tunnels go,” he says.

That precise placement allows the knee to work close to normally. “The old way, the knee worked but it didn’t work like it was supposed to,” he says. “With this new technique, the new ACL works the way the old ACL did.”

With a more anatomically constructed knee, the hope is that fewer patients will get arthritis, although there are no studies yet to back it up, Robinson says.

An additional refinement of the surgery is called double bundle reconstruction, says Dr. Anthony Carter of Hampton Roads Orthopaedics and Sports Medicine in Newport News. As opposed to one tendon, the ACL actually is two distinct bundles, Carter says.

So when your knee is fully extended, the front part of your ACL gets tight, but the back part remains relaxed. Then when you bend your knee, the back part of your ACL becomes tight, Carter says.

The double bundle surgery, paired with the anatomically placed tunnel, recreates these two distinct bundles, giving the new ACL a more natural rotation, Carter says. He is not performing the surgery yet but sees tremendous advantages to the technique. Early studies suggest the double bundle surgery, which is technically demanding to perform, leading to more rotational stability, he says. After surgery, you and your medical team will focus on rehab. You’ll likely begin physical therapy on the third day, Haynes says.

If your surgery was on your left knee,you could return to driving an automatic car as soon as you’re off your pain medicine,Robinson says. Patients with desk jobs can return to work within a week or two, especially if they have transportation to work.

By six weeks after surgery, patients should be ready to resume every day activities including driving even if the surgery was on the right knee. Physical therapists and trainers also are working to prevent the need for ACL reconstruction surgery, Carter says. “Some of it you can’t prevent,”Carter says. “But you can adjust the way people use and strengthen muscles.

There are very high-risk ways people jump and land. You can teach people how to land properly.”

A meniscus tear is another common knee problem. Haynes compares a meniscus tear to a splinter coming off a two-by-four. You don’t try to hammer the splinter back down. Instead, you cut it off and sand the board back down smooth, he says.

A meniscus repair is often done at the same time as an ACL reconstruction. In fact, it’s better to treat a meniscus tear at the same time.

One factor is where the meniscus tear is located. That’s because the outer onethird of your meniscus has a blood supply,but the inner two-thirds does not.
The lack of a blood supply for the inner two-thirds means those tears may not heal well after surgery, Haynes says.

However, when a surgeon performs ACL reconstructive surgery, the knee fills with blood even over the two-thirds of the meniscus that normally lacks a blood supply. That allows the repaired meniscus to heal, Haynes says.

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