Things to Consider

Before your surgery

Try to regain your range of motion prior to the surgery. Some patients with a high grade medial ligament injury may need a brace prior to ACLR surgery to allow it  to heal.  Avoid shaving your own leg or wearing knee sleeves as they cause pimples. If you have a pimple around the knee or any break in the skin notify Dr Vertullo’s rooms ASAP as your surgery will have to be postponed.

WHILE IN HOSPITAL

Be involved in your physio and pain medication decisions. Pain control is essential to achieve a good outcome.  It is vital not to fall over after surgery to avoid wound damage, particularly on wet tiles.

DURING RECOVERY

Rest, Ice and Elevation is important for the first week. If you experience increasing pain, swelling or wound redness etc, notify Dr Vertullo ASAP.  For the first week you will be in a splint, but you can put full weight on the knee.  During this week, you can start straightening your knee a few  times per day.  After one week, the brace comes off and rIding an exercise bike will improve your outcome and increase flexibility,

AFTER RECOVERY

It will take over 8 months for the graft to become a living part of you. The graft acts as a scaffold and slowly the body turns the hamstring graft into a living part of you.

For More Information

Visit :

http://www.knee-surgeon.net/ACL_Reconstruction.html

http://www.knee-surgeon.net/Meniscal_Repair.html

An ACL tear is a very common injury that results in the knee joint becoming unstable.

70% of  ACL tears occur without contact, typically when a player sidesteps at speed while trying to avoid an opponent. The knee hyperextends on contact with the ground, tearing the ligament. The amount of pain and swelling that occurs is usually due to other injuries such as meniscal tearing, bone bruising/ fracture or damage to other ligaments.  The outcome after reconstruction depends on the meniscal cartilages. Damage to these results in long-term osteoarthritis.

If the ligament is not reconstructed prior to attempting to return to sport or activity, the knee can buckle or pivot when changing direction and cause further meniscal damage. The best time to reconstruct the joint is after the first injury with missed ACL tears being a major cause of osteoarthritis.

Reconstruction of the ACL involves an operation to place a new graft usually made from two hamstring tendons in place of the torn ligament.

Just repairing the ligament doesn’t succeed unless it has been pulled off with a small piece of bone.

Via keyhole incisions, under arthroscopic visualization, two sockets or tunnels are created in the femur and tibia with the new graft threaded into place between the sockets. The graft is held in place with a metal button on the femur and a screw /staple on the tibia.  At the same time, any meniscal damage is either repaired, left alone or shaved depending on the pattern of meniscal injury.  Other surgery can be required to fix other ligaments or chondral damage.

An arthroscope in the knee

Q&A

Frequently Asked Questions About ACL Reconstruction

Q: Why do I need an anterior cruciate ligament reconstruction?

There are two types of patients for whom Dr Vertullo recommends anterior cruciate ligament reconstruction:

Group One - Active patients with an acute, i.e. recent anterior cruciate ligament rupture with or without simultaneous meniscal cartilage damage.

Group Two – Patients who have torn their anterior cruciate ligament at some stage in the past and have either gone on to develop ongoing feelings of instability or a meniscal cartilage tear.

If patients are older, less active and with either no feelings of instability or no cartilage damage, the surgery is undertaken on a case by case basis.

Q :What are the benefits of having my anterior cruciate ligament reconstructed?

The main aim is to prevent buckling or pivoting episodes of the knee which often go on to cause medial meniscal cartilage damage. If a patient tears their medial meniscus and loses it, they have a very high rate of osteoarthritis at 10 to 20 years post injury. If a patient doesn’t damage their meniscal cartilage, irrespective of what has been undertaken to the anterior cruciate ligament, they do well long-term . The main reason to have the anterior cruciate ligament reconstruction is to protect the knee from arthritis and knee replacement longer term by preventing meniscal cartilage tearing.

Q: Can I walk after the surgery and do I need crutches?

To allow the anterior cruciate ligament graft to heal to the bone successfully, Dr Vertullo requires the patient to utilize a brace and crutches for one week. At one week, the vast majority of patients can come out of the brace and start mobilising slowly. At one week post surgery, physiotherapy is commenced.

Q: When can I return to work?

Most patients can return to work utilizing the following guide:

School/university students can usually return at one to two weeks post surgery.

Office workers can usually return at two to three weeks post surgery, depending on their transport requirements.

Heavy manual labourers or tradesman can usually return to work by six weeks but in a suitable duties capacity with expectations of full duties at three months.

Patients who work in very high demand activities such as police officers, roof tilers, merchant seaman, firefighters, armed forces personnel etc often can’t return to work until three months post surgery.

Q: When can I return to sport or other activity?

Most patients are able to return to pivoting sports at eight to nine months. Patients can ride a bike within a few weeks of surgery and most patients can go back and play golf at eight weeks and go back surfing at three or four months. You can drive once you are out of the brace and safely controlling the vehicle.

The restriction on the pivoting activity is because this is the prime stress that leads to stretching out of the anterior cruciate ligament graft. Activities that are also precluded would include touch football, netball, wake boarding, skiing etc.

Q: What do I have to be careful of after the surgery?

As the graft is a scaffold and your body grows into it over the nine months, slipping over on wet tiles is a prime cause of graft injury before it heals.

Post surgery you should notify us immediately if you notice any increasing pain or swelling, either in the knee which could be a sign of infection or in the calf which could be a sign of a deep venous thrombosis.

In general, if you are getting better every day, the swelling is reducing and you are able to slowly increase your activities, then your post operative recovery is proceeding as normal.

Q: What are the complications of this surgery?

Dr Vertullo has invented a technique of infection prevention by soaking the anterior cruciate ligament graft intra operatively with antibiotics. This has reduced the infection rate from approximately 1% down to 0% over the last 1,000 anterior cruciate ligament reconstructions he has undertaken. Hence, while infection can occur, it is much less likely using this technique.

Other complications can include thrombosis in the leg, known as a deep venous thrombosis. You will be given a heparin injection while in hospital and then you will be asked to take low dose Aspirin, of 100 mg per day for three weeks after the surgery to decrease the risk of blood clots on the lungs and legs.

In addition, some patients notice numbness around their scars. Usually, if this occurs it is limited to the top end of the calf and it will decrease in time. Occasionally, however, patients always have a small patch of numbness around the wound and sometimes it never completely recovers normal sensation around the wound.

There is a 5% chance of needing a repeat arthroscopy either because the patient gets too much scarring over the graft, known as a Cyclops lesion or a meniscal repair fails. A Cyclops lesion is a  lump of scar tissue prevents the knee from straightening properly and patients get a clunking sensation when they attempt to do so. If you have a meniscal repair simultaneously to the surgery, 80% of these heal spontaneously but 20% fail to do so and hence these patients need repeat arthroscopy because of meniscal tearing or non healing.

More very rare complications would include injuries to nerves and arteries.

When can I leave hospital ? Usually the next day.

What size scars will I have ?

You will have two 1cm incisions either side of your patella tendon, with a 3cm incision to harvest the hamstring just to the inside of your top of your tibia.

Will I need a Catheter in My Bladder or a Drain  in My Knee ?

No

Phase I Week 0-1

1. ✴Wear splint, but gently extend knee with it open 4-6 times/day
   

2. ✴Keep your pain under control
   

3. ✴Control swelling with Rest/ Ice / Elevation +++
   

4. ✴Avoid knee flexion
   

5. ✴Weight bear as able on crutches
   

Phase II Week 2-6

1. ✴Wean brace & crutches as confidence & coordination allows
   

2. ✴Restore heel/ toe gait pattern
   

3. ✴Continue gentle extension
   

4. ✴Start stationary bike: Increase flexion gently as able
   

5. ✴Static proprioception exercises
   

6. ✴Avoid resisted hamstring / passive stretches
   

7. ✴Control persistent effusions
   

8. ✴Two leg quarter squats & pain free step ups
   

9. ✴Commence light hydrotherapy
   

Phase III Week 6-12

1. ✴Increase bike: Aim full flexion
   

2. ✴Correct gluteal control, tight hamstrings/ ITB/ gastrocnemius
   

3. ✴Start dynamic proprioception drills
   

4. ✴Start Rower/ Stepper/ X-Trainer
   

5. ✴Quads/ Hamstring functional activation & add half squats
   

Phase IV Week 12-20

1. ✴Start light jogging
   

2. ✴Sports specific drills
   

3. ✴Cardio & muscle endurance
   

4. ✴Agility exercises
   

Phase V Week 20-36

1. ✴Sports specific exercises, ie pylometrics & ball drills
   

2. ✴Agility run/jump combinations
   

3. ✴Improve  power/ endurance
   

Rehabilitation & Physio