An ACL tear, and surgical repair

So… what exactly is an ACL (anterior cruciate ligament)? Well, anterior means front, cruciate means to cross in a diagonal kind of way, and ligaments are tough fibrous bands of tissue that connect the bones in our human joints. So in plain english the ACL is a ligament in the knee which connects the thigh bone to the shin bone… it is situated close to the front of your knee and runs across the PCL (another ligament) in a diagonal kind of way. Make sense? If it still doesn’t, don’t worry… the figures in this article should elucidate further. The ACL is arguably the most important ligament in the knee joint. Its major functions are to resist excessive twisting or rotation of the knee, and to prevent the tibia (shin bone) from sliding too far forward underneath the femur (thigh bone) when one comes to an abrupt stop. This ligament is so important that without it, the average person’s knee would constantly “give out on them” while they perform seemingly mundane tasks. This super important knee ligament may be injured or torn due to a direct forceful blow to the front or side of the knee. ACL tears are common in sports such as football (soccer), and basketball where rapid acceleration, deceleration, and changes of direction are common.

An ACL tear is exactly what it sounds like: the anterior cruciate ligament in the knee is torn. In some cases the ACL may only be partially torn and is classified as a grade I or II sprain. In other cases, the tear is complete and is termed a rupture. A complete rupture of the ACL can occur either in the middle of the ligament, or it can be of the avulsion variety where the force of the injury has detached the ligament from one of its attachment sites: at either the tibia or the femur. As you may have guessed, an ACL rupture is much more serious than a sprain. It is an injury that almost always requires surgery for healing to occur, and yes, it hurts like hell.

Like most acute injuries, an ACL rupture is extremely painful at the time of injury. This acute pain may subside within minutes, and in some cases the injured individual may actually attempt to keep playing whatever sport they were playing before the injury. This of course doesn’t work for very long. As soon as the individual “plants” the injured leg to either decelerate or abruptly change direction, the knee will probably buckle and send them crashing to the hardwood, grass, turf, or whatever surface they are playing on. The tell tale signs of reduced mobility and diffuse swelling in the knee joint will be more evident the next day. If this sounds like you or someone you know, you would be wise to make sure the injured individual gets to see an orthopedic surgeon as soon as humanly possible.
 
 

Initial signs of an ACL tear and beneficial first aid actions

An individual who has just experienced an ACL tear will begin to notice a number of “tell tale” initial signs in the first few hours after the injury. It is very important to note that these initial signs and symptoms are NOT conclusive evidence of an ACL tear. Even if you or someone you know experiences all these signs and symptoms, you should still confirm with your surgeon before you jump to conclusions. Put it this way… a person who has an ACL rupture will experience the following symptoms but it isn’t necessarily true that everyone who experiences these symptoms has completely ruptured their ACL.

1. Pain in the knee joint: An ACL injury is one of the most painful injuries an athlete can sustain. Even some of the “baddest” athletes in the world with the highest pain thresholds let out audibly loud screams due to the pain of this injury. If you screamed or even cried at the time of your injury, it is nothing at all to be ashamed of… the pain from a torn ACL is pretty intense.
2. Significant swelling around the knee joint: A considerable amount of swelling will typically occur around the knee joint in as little as 1 – 2 hours after an ACL tear as the body releases healing factors and tries to prevent further damage to the knee.
3. Loss of mobility in the knee joint: This goes hand in hand with the significant swelling that occurs right after an ACL injury. The swelling acts as nature’s version of a splint and prevents you from overextending or completely bending the injured knee which effectively prevents further damage.
4. General instability in the knee: The ACL is the major stabilizing ligament in the knee. Thus it is very common for an individual with a ruptured ACL to feel like their knee may buckle at any moment while doing something as simple as walking at a moderate pace.

 
The following 3 strategies will prove immensely helpful right after a serious looking knee injury that suspiciously looks and feels like an ACL tear. These initial steps will help to jumpstart the long but rewarding process that will hopefully culminate in a full recovery. The top priorities immediately after injury are to: get the swelling in the injured knee down, stay positive, and book an appointment with a skilled/experienced orthopedic surgeon. This is what everyone told me when I got injured and I must say that in retrospect, it was very sound advice. However, I quickly found out that there is a pretty big difference between (a) telling someone what to do and (b) giving a detailed explanation that empowers another person to follow through with appropriate action. If it’s okay with you, let’s go with option b.
 
Get the swelling in your knee down…
The glorious human body is “programmed” to react aggressively to any perceived injury with body chemistry that prevents further injury and promotes healing. In the case of a torn ACL, the body reacts by sending the soldiers of the circulatory system – white blood cells and platelets – to provide a “natural splint” around the knee that serves to immobilize the joint and prevent further injury. This process is what you may commonly know as swelling or inflammation. Though inflammation in moderation actually promotes healing, the body often reacts too aggressively with excessive swelling that distorts diagnostic test results and slows down recovery. This is why it is important to reduce swelling to a manageable level after an injury.

Rest, Ice, Compression, and Elevation (R.I.C.E) are the major actions that can help reduce excessive swelling in an injured knee. Rest is self explanatory… avoid unnecessary movement. Wrap an ace bandage around the injured knee to achieve Compression. While wrapping the injured knee, the ACE bandage should be applied tightly enough to provide compression, but not too tight as to severely impede the flow of blood. You will be able to tell if the bandage is on too tight because you will start loosing feeling in the lower extremity of your leg which often manifests as a tingling sensation. Apply Ice to the injured area by putting some ice cubes into a Ziploc bag and placing it on top of the ACE bandaged knee. This is an easy and cost-effective way to ice the injured knee without making a drippy mess. It is also important to Elevate the injured knee so that it rests at a height above that of your heart. Elevating your knee will encourage the excess blood that has pooled around your knee to drain out of the injured area and reduce swelling. A good way to elevate an injured knee is to stack some pillows on a couch and rest the calf of the injured leg on the pillow stack while laying flat on the bed or couch.

 
Stay Positive…
Being injured is not a fun experience and your feelings might vacillate between fear, worry, anger, and frustration. It is extremely important to actively work to keep your spirits high to avoid falling into a dangerous spiral of depression. Being around some close trusted friends can keep the mind positive. Having a good laugh while watching your favorite comedy show is a good thing for the mood. If musically inclined, you can find therapeutic relief by playing an instrument that doesn’t worsen pain. Religious people may want to use this time to pray and meditate to soothe the nerves. The general idea should be clear by now… replace fear “and worry with lightheartedness, inner peace, and laughter at all costs. When the negative feelings come (and trust me… they will), don’t try to fight them directly. I would recommend trying to look for wonderful memories and thoughts to replace them with. Please DO NOT drink alcohol in excess or smoke anything to numb the senses or alter your consciousness. Being “high” or intoxicated will induce clumsiness, and probably increase the chances of further injury. It wouldn’t be a good idea to impair your sense of balance any further as you will probably already be wobbly on your feet.
 
Book an appointment with an experienced orthopedic surgeon…
Seeing an experienced orthopedic surgeon is key to uncovering the severity of your knee injury. All that is clear prior to seeking professional help is the that your knee is injured, swollen, and painful. However, the extent of the damage is still a mystery. Use the internet or pick the brains of knowledgeable people who have had surgery to find the best orthopedic surgeon around, and make an appointment to see him/her. It is generally preferable to get a surgeon who routinely does ACL reconstructions so that you can be sure the surgeon has had recent and ample practice with surgical knee repair. You are going to have to live with your leg for the rest of your life so I would seriously recommend taking the appropriate care and time to pick the best surgeon you can find. Please make sure your insurance will help with the bills since surgeries tend to be expensive.

Use the time preceding your appointment to think about questions that you may want to ask your surgeon and write them down. I personally use the “Notes” app on my iPhone for things like this because I know I will probably have my iPhone on me wherever I am. When you get to your appointment, you can simply call up these questions and ask them. This is a good way to be certain you won’t omit any of the important questions you’d like to have answered. Please don’t be shy! Ask the questions you thought up. You are paying for this hospital visit so use your money well.
 

Diagnosis

Going to a hospital in which human beings are routinely cut open and sewn back up can be daunting. Don’t be ashamed or feel like less of a man or woman if you need a friend to go with you. Your friend could help keep you grounded as your surgeon rattles off a diagnosis and a list of corrective actions at your disposal. Do what you need to do in order to keep yourself comfortable and at peace. Just make sure that whatever you are doing to keep calm doesn’t entail going out of your way to harm yourself or anyone else.

A good surgeon will use a combination of the lachman’s test, x-rays, and an MRI (Magnetic Resonance Image) to confirm or refute the incidence of an ACL rupture. Unless you have had extensive medical training, you are probably wondering to yourself: “What on earth is an MRI, and what is a lachman’s test?” and why should I believe a diagnosis that comes from either of these diagnostic tools? Well then, let’s visit the scientific realm to explain these diagnostic methods and techniques.

The lachman’s test is one of the best low-tech predictors of an ACL tear. In this test, the surgeon will grab the hamstring/femur combination of the injured leg with one hand and the tibia/calf muscle combination of the same leg with the other hand. Next, he/she will attempt to slide the tibia forward past the femur (recall that the main function of the ACL is to prevent this very motion). If the surgeon can feel a sharp end point which prevents him/her from pulling the tibia any further forward, the ACL is probably still intact and the biggest worry has been averted. If the surgeon can pull the tibia past the femur with little or no resistance, the ACL is probably completely torn. This test is not 100% conclusive because excessive swelling in the knee can impair the surgeon’s perception. For this reason, the best surgeons also ask to see an MRI and an x-ray of the injured knee before making a conclusive and definitive diagnosis.

MRI or Magnetic Resonance Imaging is a non-invasive imaging technique that is widely used in medicine to visualize soft tissue inside the human body. If you’re the curious type, you can look up this article to learn more about how MRI actually works. One very common application of the MRI imaging technique is to confirm or refute suspected ligament, tendon, or muscle tears. At the end of your first surgical visit, you will probably be asked to schedule an MRI with a recommended clinic, and a return appointment where your surgeon can confirm your diagnosis. Don’t worry, MRIs don’t hurt one bit… they are just really loud. Your MRI technician should offer you some earplugs before the imaging session begins. Remember that the M in MRI stands for magnetic so be sure to tell your technician about every bit of metal that you have on you or in you. If the magnet is powerful enough, it will actually try to pull out bits of metal right from your body. So please think carefully about any piercings, metal plates, screws, rods, etc, that you have in your body and inform your technician so you can be advised on how to remove them or shield them from the magnetic field. It usually takes about 40 minutes to get a good image of an isolated body part such as the knee. After the MRI is complete, most MRI clinics will be able to send the digital image directly to the surgeon without any need for you to interfere. This gives the surgeon ample time to study the MRI results, come up with a conclusive diagnosis, and a potential plan of attack to overcome the injury before your next surgical visit.
 
 

Treatment options for an ACL Tear

There are two main modes of treatment that people can follow after an ACL injury: conservative or surgical. The conservative mode of treatment mainly involves physical therapy without any surgical intervention. The surgical mode of treatment involves surgical intervention and a lengthy rehabilitation process which will hopefully lead to a full recovery. For the purposes of this article, we’ll discuss the surgical modes of treatment only.

A ruptured ACL cannot be reattached or sewn back together as far as the current state of medicine is concerned. Thus, the de facto surgical treatment for this injury is to completely replace the ruptured ACL. Armed with that bit of knowledge, you may ask: “ What is used to replace a ruptured ACL?” Any good surgeon will present you with the answer to that very question once you have decided to have reconstructive ACL surgery. Below, we will discuss some of the most common tissue sources used by orthopedic surgeons to replace a torn anterior cruciate ligament.
 
Graft tissue option 1: Bone-Patellar-Bone (BTB) graft
This is the most popular graft choice for the surgical reconstruction of a professional athlete’s ACL in the United States. Most surgeons refer to this as the “gold standard” of ACL tissue replacement grafts. I would personally recommend it because it was used to repair my knee, and I have been pretty happy with the results thus far.

The patellar tendon connects the patella (kneecap) to the tibia. Strangely enough, even elite athletes of the highest caliber can function at extremely high levels without the inner third of the patellar tendon. For this reason, the inner third of an individual’s patellar tendon – typically about 10-11mm wide – can be harvested and used to replace a ruptured ACL. Since the donor tissue for this graft choice comes from the recipient, it is referred to as an autograft which literally means “graft from self”. The bone patellar bone graft is then implanted at fixation sites at the tibia and the femur using biocomposite screws. With this mode of ACL surgery, one can expect to be on crutches for 4-6 weeks depending on whether or not the meniscus was also torn at the time of the injury.

 
Graft tissue option 2: Cadaver achilles tendon graft
The achilles tendon connects the calf muscle to the heel bone in the foot. This tendon is often harvested from the dead, sterilized using gamma irradiation, cryopreserved, and used in ACL replacement surgeries. Since this graft is harvested from a source outside the recipient, the technical term for it is allograft or “a graft from another member of the same species”. Sterilization of this donor graft tissue is a double edged sword. On one hand, sterilization kills off the cells of the donor so that the immune system of the recipient doesn’t react adversely to it. On the other hand, prolonged sterilization of the graft can actually make it susceptible to failure after it has been surgically implanted into the donor. Of late, the medical community has made efforts to reduce the intensity of the irradiation conditions to avoid excessive weakening of the donor achilles tendon. Recent studies show that lessening the irradiation conditions improves the longevity of achilles tendon grafts, but may also unfortunately increase the risk of tissue rejection. Like the bone patellar bone graft, it is implanted at fixation sites at the tibia and the femur using biocomposite screws. You can expect to be on crutches for anywhere between 3-6 weeks after surgery depending on whether or not a meniscus tear was also sustained.

 
Graft tissue option 3: Hamstring tendon tissue graft
The hamstring starts at the base of the hip, and runs along the back of the thigh all the way to the bones of the lower leg. The hamstring is the antagonistic muscle group to the quadriceps and plays a very important functional role in knee flexion and hip extension. The hamstrings are made up of the following entities:

• Bicep Femoris
• Semitendinosus
• Semimembranosus

As with most other human muscles, the hamstring is connected to its bone attachment sites by tough fibrous tendons. Since the semitendinosus muscle serves as an accessory hamstring, surgeons usually harvest the tendons that connect it to the bones of the lower leg for use as surrogate ACL graft tissue. The graft is typically harvested from the hamstring of the injured leg. Specifically, the surgeon will make an anteromedial incision just below the knee to harvest a part of the hamstring and strip it down to get at the tendons. He may also harvest the gracilis tendon as well for use as graft tissue. The harvested tendon(s) will be folded and braided to produce a graft with increased strength and integrity. “The graft is then fixed in place in lieu of the ACL using biocomposite washers and screws.

 
 
Now that you have been presented with all the available options for tissue graft types, your task is to make a decision as to which graft option you would like to use for your surgery. The very best orthopedic surgeons will make themselves available to you via phone or email to answer any questions that may crop up as you decide on which graft choice you feel will be best for you. I would recommend taking advantage of your surgeon’s availability to get all your questions answered as you go through the thought process. Once you have decided, you can now shift all your attention towards preparing for the ordeal also known as surgery

This glorious universe that we both live in doesn’t discriminate… No matter how rich, nice, good looking or smart we may or may not be, we will all have challenges and difficult moments in life. When the inevitable challenges present themselves, it is important to remind yourself that the universe isn’t picking on you because it hates you. Rather, it is my belief that challenges (no matter how unpleasant) are there to force us to become more thoughtful, creative, and resourceful. Through the non-trivial challenge of making a full recovery from ACL reconstruction, you will probably learn a lot more about nutrition, your physical anatomy, and your character than you would have otherwise known had you not been stricken with this injury. I can say this with confidence because that was exactly what happened to me. Godspeed on your road to a full recovery.
 

This article is an excerpt from “In Kneed of Repair… Getting through ACL reconstruction”. An interactive eBook designed to guide you through ACL reconstruction and recovery. You can buy the full iBook for iPad or Macintosh on the Apple iBookstore
 
 
Without Wax
Oyolu B.C. Ph.D.
chubaoyolu.org
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