Arthroscopic Ligament Surgery

What is ACL?

ACL is the short name for a ligament of the knee called Anterior Cruciate Ligament. Ligaments are tough chord-like structures which join the bones. These provide strength to the knee. There are four such ligaments in the knee - one on the inner side (MCL), one on the outer side (LCL), and two in the middle. The two middle ligaments cross each other, and are therefore called cruciate ligaments. Of these, the one in front is called Anterior Cruciate Ligament or ACL .

What happens if ACL is torn?

• The usual history is the twisting injury of the knee followed by pain and swelling. A cracking sound (pop) is heard .
• The patient may experience that his knee has moved in an odd way.
• X-rays are usually normal, and hence this injury is considered a ‘minor’ sprain. The patient may gradually improve, and feel almost ‘normal’ over a period of time. He almost forgets about the knee, when one fine day he twists his knee again, and feels pain, swelling and instability.
• Feeling of instability (giving way) of the knee prevents one from rigorous activities such as running, jumping etc. People with low-level physical activity may be able to manage despite a ruptured ACL, but in others the knee feels weak.
• One may feel ‘unsure’ of the knee or the knee may actually give-way off and on. Each episode of ‘giving-way’ causes further damage to the knee by rupturing the meniscus (cushions). This, in turn, may cause injury to the caps (cartilage) covering the bones. The natural squeal of such continuing insult to the knee is early wear and tear of the knee (osteoarthritis). This becomes a source of constant pain and swelling. At a later age, if such arthritis becomes troublesome, knee replacement may be required.
• MRI is one way to confirm the diagnosis of a torn ACL. Patient's symptoms of 'giving way' and clinical examination by the doctor can confirm to reasonable surety that the ligament tear is complete. The same is further confirmed on arthroscopic viewing.

What are the different ways of treating ACL tear?

• Treatment with physiotherapy: In patients with low-level of physical activity (office kind of a job), treatment with physiotherapy may ‘tune’ the knee to control itself, despite a torn ligament.
• ACL repair: This is a new technology, where in some fresh ACL tears, it is possible to repair them, there and then. This needs special tools and skills to do so. This is done by key-hole (arthroscopic) surgery.
• Reconstruction of ACL: Sometimes, ACL is badly torn, and if patients come late, ir may not be possible to repair the ligament. I such cases, the only option is to make a new ligament (ligament reconstruction). This is done by placing a substitute ligament from your body (graft) next to the torn one. The graft is made from dispensable tendons around the knee and fixed where the original ligament was. With time the ‘new ligament’ takes blood supply from the body, gets incorporated, and functions somewhat like the original ligament.

Will I need surgery?

It is possible to lead a normal life despite a torn ligament provided you are willing to modify your lifestyle, which means low on physical activity and sports. If you are not confident about your knee (walking on irregular ground, running and stair climbing) then you need surgery. If you want to pursue active sports life, surgery is a must.

If you do not follow these restrictions and continue to play with a weak knee, it will lead to repeated injuries further damaging the knee. Such repeated injuries eventually lead to permanent damage to the knee. Surgery of ACL reconstruction is never an emergency, you can give it time and a trial of physiotherapy to see whether your body adapts to torn ligament. "Modify your life to fit your knee or modify your knee to fit your life" is the standard quote

How is ACL reconstructed?

It is a standard practice these days to do ACL reconstruction, arthroscopically. The operation consists of the following steps.

• A diagnostic arthroscopy to re-confirm the diagnosis (which of course would have been already confirmed by MRI), and take stock of the associated damage to other structures inside the knee such as meniscus etc.
• The spare tendon (graft) is taken out from back of the knee by tunneling technique using special tools.

• Graft designed to the shape of a ligament.
• Graft is inserted in the knee through drilling technique, without opening the knee.
• The graft is fixed at two ends by modern fixation devices, for which no extra cutting is required.

The fixation devices used are small 'button' and screws, all imported from the best companies of the world. These are self-dissolving or that of plastic, and hence do not raise alarm on metal detectors.

All this is done by key-hole surgery, without opening the knee. We use dissolvable stitches, and hence no need for stitch removal . There is minimum visible scar. The wounds are covered with water-proof dressing so that one can take bath, the very next day.

How much does the surgery cost ?

Cost may vary from case to case depending upon the technique and the implants used. These surgeries are generally covered under medical insurance. You may discuss the details when you come for fixing the date for the surgery.

How long is the procedure?

The actual duration of the surgery is approximately 45 mins. to 1 hour. One needs to spend some extra time in the OT area before and after surgery.

Salient features of our Technique

We have standardized our technique for getting best results. Following are the salient features of our technique:

1. Fresh ACL tears: We repair where others reconstruct. This is a new concept. There are a number of cases, where a freshly torn ACL can be repaired, hence obviating the need for taking graft from the body. Repaired ligament works as good as original. We have a series of such successful cases, and have even published our technique.

2. Old ACL tears: Not all ACL tears are similar. We have developed a menu approach to ACL reconstruction, which means we make changes in our technique based on what is most suitable for the type of ACL tear in your case.

We preserve the normal tissues, and not remove them, as far as possible. We believe that the torn ligament is not useless as it does have blood supply which is so much necessary for re- vascularization of the new ligament (the graft). For this we modify our technique case to case:

• Preserve the one bundle: It is now well-recognized that ACL is made up of two distinct bundles, and not both are torn all the time. We have mastered the technique where we preserve the bundle which is intact and carefully reconstruct the one which is torn.
• Stump re-a1achment: Even in cases where the ligament is completely torn, we do not remove the torn ligament, and rather reattach it to the new ligament. Though the torn ligament has no strength, but it does have blood supply. We make use of this aspect in re-vascularisation of the new ligament. We call it 'buddy' technique.
• ACL stump preservation: Even in cases, usually old cases, where only a small stump of ACL tissue is left, and it's not possible to re-attach it, we preserve the stump. This has been shown to give better 'feel' of the new ligament as the stump does have nerve fibers.

We sometimes add extra-articular ligament (extra-articular reconstruction) to support the newly-constructed inside the knee ligament. This is required for patients in demanding/ athletic professions.

1. Our technique involves using Hi-tech devices (Radiofrequency prob, motorized shaver etc.), which are one time use. These make it possible to do surgery with minimal tinkering inside the knee.

2. We have an aggressive, well -coordinated, goal oriented post-operative rehabilitation programme.

Needless to say, all operations are done by the a team of specialists knee surgeons.

What are the results of ACL surgery?

ACL surgery is one of the very successful operations. But, in a surgery which involves healing of tissues and creation of substitute of natural body parts, a lot depends upon a patient’s healing potential. Even in the best of hands this operation is successful in 90% of cases. There are 10% cases where the graft does not take blood supply from the body, and remains weak and sometime ruptures.

What is the procedure of getting operating?

You are admitted to the hospital for one day. Some tests are conducted on you to make sure that your body is fit for anaesthesia. The operation is usually carried out under a spinal anaesthetic (an injection in your back), or sometimes under general anaesthetic.

Before undergoing surgery you may be prescribed medication. Give us a list of all medicines that you are taking or have recently taken, as there may be cross reaction between medicines.

On the day of surgery:

You may have to be fasting for 4-6 hours before surgery. The operation takes about 1 hour, but you will be in the operation theater complex for nearly 4 hours.

After the surgery, the nurses observe your recovery to make sure that your blood pressure, pulse, other vital signs, and the operated site are normal. In the recovery ward, you may have a bandage or temporary brace on your knee. You will be discharged from hospital on the day after surgery.

Recovery period:

You will be up and about with the support of a crutch on the second day after surgery. You will be using crutches for first 2 wks. You can start going to the office after 2 wks but with restricted mobility. It takes nearly 3 months of physiotherapy to feel normal in day to day activities. It might take upto 6-9 months to become fit for sports.

We have devised a protocol of physiotherapy for ACL patients in 4 phases. You will need to be under supervised physiotherapy either at our centre or with our associate physiotherapists.

We advise that you contact our physiotherapy chief immediately after your surgery for well coordinated care.

Care after surgery:

You will be advised the following:

1. Application of ice packs for 20 minutes 4 times a daily for the first few days.

2. The use of the crutches and occasionally a knee brace for a variable period.

3. Medication to relieve pain and discomfort.

4. Antibiotics to reduce the risk of infection.

Most patients will go home after 24 hours, and rest of the treatment will be at home. Depending on the type and extent of the surgery, you will be advised when you can resume your normal activities.

General Risks of Surgery:

The following is the list of possible risks of undergoing this operation. These are not to alarm you but to inform you. We take all care to keep these to the minimum, but they do occur once in a while, unfortunately.

Anaesthesia -related risks: Anaesthesia techniques have become fairly safe now, but an odd patient still runs the risk.

Surgery-related risks: The following do sometime happen.

• Wound infection: Treatment with antibiotics for long period may be needed.
• Haematoma (an accumulation of blood inside the knee and around the surgical site), may need aspiration under local anaesthesia.
• Slow or poor healing (most likely in smokers, people with diabetes, and in elderly people).
• Knee stiffness: Knee stiffness is a complication in any knee surgery. With currently practiced rehabilitation where we allow immediate knee movement and keep close watch on physiotherapy, these are now-a-days rare.
• Poor graft re-vascularisation and re-rupture: This occurs in 5-7 % cases all over the world. This is due to poor healing of the ligament. Surgeon has no control over it.

Our philosophy: Most important, we have a philosophy of treatment. We take every patient as a human being with different requirements – physical and psychological. We customize our treatment to patient's need. Our aim is to give our patient the experience of having gone through the treatment, what we would expect for our own relative. For us, by choosing us their doctor, the patient is giving us a great honour, and we value it. To showcase that we care, all our operated patients have direct access to cell phones of our team, including that of the chief surgeon.