Anterior Cruciate Ligament (ACL) Reconstruction Surgery

What is ACL reconstruction surgery?

ACL reconstruction surgery is a surgical procedure to repair a torn ACL. The ACL is one of several tissue structures in your knee. This provides stability and support to your knee.

The other three major knee ligaments are:

• Lateral collateral ligament (LCL)

• Medial collateral ligament (MCL)

• Posterior cruciate ligament (PCL)

The above four ligaments hold together your knee hinge joint where the thigh bone, shinbone, femur, and tibia connect.

The ACL maintains your knee balance by avoiding side-to-side movements. ACL injuries are common with athletes who take part in sports such as football, basketball, hockey, and skiing.

An ACL tear ensues when the knee is put under pressure during fitness or sports activities. Specifically, it happens when:

• You jump and land awkwardly

• Suddenly change direction after slowing down

• Make a sudden stop

• Have a collision or sustain a direct blow to your knee as happens with a tackle in football

Why would you need ACL reconstruction surgery?

This surgery aims to regain your knee stability. That way, you retain and obtain the same full range of motion as before the injury.

ACL reconstructive surgery is necessary to repair a torn ligament especially if you are experiencing persistent pain or are actively involved in sports.

Your surgeon may recommend ACL reconstruction surgery under the following conditions:

• If you are experiencing persistent knee pain

• If you are young and active

• In case you buckled your knee while walking or partaking in other daily activities, because of the injury

• You are an active athlete and wish to continue in this line

Types of ACL grafts

During ACL reconstruction surgery, your surgeon replaces the torn ACL with a tendon or graft that will function as the ACL.

The graft can be obtained from donor tissues of developed tissues from your knee (autograft).

The grafts used in ACL reconstruction surgery fall under three categories:

Hamstring tendon graft

This is by far the most popular graft. The hamstring tendons are located at the back of your thing.

During ACL reconstruction surgery using a hamstring tendon graft, your surgeon removes the gracilis and semitendinosus hamstring tendons. The two tendons are doubled to form a four-strand graft.

Hamstring tendon grafts are easily available. Also, the drill holes needed are relatively smaller.

Hamstring tendon grafts have no blocks at both ends and are difficult to anchor at the knee.

Patellar tendon graft

This tendon graft is located beneath your kneecap. During surgery, your surgeon removes the middle third portion of a healthy patellar tendon.

The procedure also entails the removal of a small bit of shin and patella bone connected to both ends of the tendon.

Your surgeon will then graft the section of the tendon on that part of the knee where the ACL has been removed.

The presence of bone blocks on both sides of the patellar tendon graft makes it easier for the surgeon to fix it in place.

Removing the patella tendon may cause such side effects as anterior knee pain and inflammation.

Allograft donor tissue

This option entails the use of donor tissues retrieved from a cadaver. It is rarely used and mainly applies to patients who have had ACL reconstruction procedures in the past or individuals who have a less active lifestyle.

The choice of graft depends on:

• Your surgeon’s preference

• Whether the graft is linked to knee injuries

• Your age

The choice of one graft over another does not carry any benefit.

With allografts, however, their use in young athletes could be accompanied by an increased risk of failure.  For that reason, allografts are primarily recommended for patients aged 35 and above.

Surgical techniques in ACL reconstruction surgery

An arthroscopic procedure is the most common technique for performing ACL surgeries.

This involves inserting a long, thin surgical tool called an arthroscopy with a small camera on the end through the small incisions made by your surgeon in the knee joint.

ACL reconstruction surgery may also involve open surgery, though this is not popular.

Arthroscopic surgery for ACL reconstruction is based on two main techniques:

Single-bundle reconstruction

This technique involves drilling bone tunnels into the thigh bone (femur) and shinbone (tibia).

Your surgeon pulls the ACL graft via the tunnel and attaches it to the exact location where the injured ACL was using a screw.

Double-bundle reconstruction

With a bundle double-bundle reconstruction, the surgeon uses two smaller grafts as opposed to a single tendon graft to reconstruct an individual ACL bundle.

The double-bundle reconstruction can be more time-consuming compared to the single-bundle reconstruction because the surgeon needs to make two extra bone tunnels before pulling through and fixing the second graft.

A double-bundle technique is associated with improved knee function and stability compared to a single-bundle technique.

Preparing for ACL reconstruction surgery

Before your ACL reconstruction surgery, your healthcare provider will arrange an appointment with a surgeon who will assess your general health and the state of the ACL injury.

This will enable him to recommend the graft that is most suited for you. You will also be issued with the following preoperative instructions:

Make sure you wear loose clothing that is also comfortable when you come for the surgery.

You will be asked to fast after midnight on the day of the surgery.

If you are on certain medications such as blood thinners, your surgeon will ask you to stop taking them for some time.

You will be asked to practice using crutches for you will need them after the procedure.

Make arrangements with your spouse, friend, or family member to drive you home after ACL reconstruction.

Your surgeon will also advise you to engage a physical therapist who will take you through various exercises before surgery.

Such exercises are useful to enhance the functional outcome following the procedure.

On the day of ACL reconstruction surgery, the surgical nurse will take you to a preoperative room so that you can change into a hospital gown.

The anesthetist places an IV in your hand to assist in the delivery of medication and fluids.

The anesthetist and the rest of the surgical team will brief you about the surgery.

The anesthetist will guide you to the operating room and administer the anesthesia. This will put you to sleep during surgery. 

During surgery

The surgeon begins by making 2-3 small incisions on your knee.

The surgeon will insert an arthroscope and the rest of the surgical tools into your knee through the small incisions made.

Using the arthroscope, the surgeon gets to view the inside of your knee on a small computer screen to which the arthroscope is attached.

The next step involves “harvesting” a segment of a tendon in case the surgeon decides to use an autograft.

The tendon is gotten from a different part of your body usually the thigh or hamstring.

The surgeon makes an incision on the identified part of the body where harvesting of graft will take place to remove a portion.

The removed graft is first cleaned, followed by trimming to fit the desired size. It is then stored in a dedicated freezer.

The surgeon uses a motorized shaver to remove the torn ACL. This creates room for replacement with the new graft.

The surgeon uses a drill to make bone tunnels via the shin femur and tibia.

The next step involves pulling the graft through the bone tunnels that have been created. It is held in place using staples or screws.

The surgeon removes the surgical instruments. Thereafter, the surgeon will tape or stitch the sites.

The site of the incision is sealed using a bandage. 

Recovery

When you wake up, you will have been transferred from the operating room to a recovery room.

A surgical nurse will closely monitor your vitals. The nurse will deliver post-surgery instructions as provided by your surgeon. She will also manage pain with medication.

After you are stable, you will be released and allowed to go home. This may take a few hours.

Make sure you have a family member or friend on standby to drive you home.

During the next two weeks of recovery, your surgeon will ask you to:

Take all the medication as prescribed, including pain medication. Your surgeon may recommend ibuprofen over-the-counter drugs like ibuprofen or prescription medication such as Neurontin to manage pain.

Place an ice pack on your knee from time to time. This will relieve pain and swelling.

Make sure the bandage that covers the incision site remains dry and clean.

Use crutches to move around. This takes off weight on the leg that has been operated on.

Most patients can resume work after a few days following ACL reconstruction surgery.

It may take up to two weeks after surgery before you can start driving again.

Your surgeon will recommend physical therapy sessions for your rehabilitation. This also contributes to your recovery.

Rehabilitation seeks to fulfill the following goals:

• Restore the lost balance and control of your leg

• Promote kneecap mobility

• Strengthen the hamstrings and quadriceps

• Assist the knee in attaining a full range of motion

Benefits of ACL reconstruction surgery

Having an ACL reconstruction surgery comes with the following benefits:

Minimized swelling and pain

You are likely to experience swelling and pain following ACL surgery. However, such pain and swelling is short-lived.

ACL reconstruction minimizes swelling and pain in your knee. It restores the functionality and stability of your knee joint meaning less inflammation and straining on adjacent muscles.

Improved stability

An ACL injury causes an unstable knee. ACL reconstruction procedure restores the lost stability in your knee joint. This increases your mobility.

Avoids future knee injuries

ACL reconstruction surgery adds stability to your knee joint. The added stability means the risk of future knee injuries is greatly minimized.

Quick recovery and resumption of your sporting activities

ACL reconstruction surgery allows you to resume your favorite sporting activity more quickly.

This enhances your mental well-being and improves your confidence.

Avoids chronic knee problems

Left untreated an ACL injury may develop into a chronic knee problem.

The knee joint cartilage may get worn out triggering the development of osteoarthritis and other chronic conditions. ACL reconstruction prevents such problems from developing.

Risks/Complications

Like other surgical procedures, ACL reconstruction also carries certain risks. These include:

• Ongoing knee pain

• Infection

• Blood clots

• If the graft is from a cadaver, there is a risk of disease transmission

• Bleeding at the incision site

• Knee weakness and stiffness

• Your knee range of motion may get lost

• Your immune system may reject the graft, resulting in improper healing

• Reaction to anesthesia

Cost of ACL reconstruction surgery in India 

ACL reconstruction surgery in India starts from Rs. 1,20,0000 to Rs. 2,50,000. The table 

below outlines the cost of ACL surgery in different cities in India:

The cost of ACL surgery in India depends on the following influencing factors: 

Hospital chosen

You will have the ACL surgery in a hospital. You may have to spend a few days in the hospital after surgery, depending on the procedure and whether there were any complications.

Consider the treatment facility of your choice before the procedure. The hospital will indicate the cost of rooms and other perks during admission. 

City or location of hospitals

The city where you have your ACL reconstruction surgery is another determining factor of the overall cost of the procedure.

Surgical consultations and hospitals in metro-cities charge higher for ACL reconstruction surgery compared with Tier 2 and Tier 3 cities. 

Type of surgery

The type of surgery that is, double-bundle ACL, or single-bundle ACL will also determine the cost of the ACL reconstruction procedure. 

Graft selection

The type of graft used to repair the torn ACL will also have a bearing on the overall cost of ACL reconstruction surgery. 

Diagnostic procedures

Any diagnostic tests and preoperative evaluation including x-rays and MRI scans carried out before ACL surgery will affect the cost of surgery. 

Post-surgery rehabilitation

The cost of physical therapy and rehabilitation will impact the overall cost of surgery based on the duration of such programs. 

Cost of operating room and anesthesia

Expenses incurred such as the use of equipment in the operating room and the anesthesia will also affect the cost of surgery. 

A comparison of ACL reconstruction surgery costs in other countries shows that it would cost you a fraction of what you would pay in another country by choosing a healthcare facility in India.

References

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