Ligament Injury and Reconstruction

Anterior Cruciate Ligament Injury

The anterior cruciate ligament, commonly known as the ACL, is one of the most commonly injured ligaments in the knee. Running diagonally through the middle of the joint, the ACL works together with three other ligaments to connect the femur (thigh bone) to the tibia (the larger of the two lower leg bones). A tearing of this ligament causes the knee to become unstable and the joint to slide forward. ACL injuries occur most often in athletes as a result of direct contact or an awkward fall. About half of all ACL injuries are also accompanied by damage to the meniscus, cartilage, bone or other ligaments in the knee.

Causes of an ACL Injury

The ACL ligament most frequently tears as a result of a sudden turn or change of direction that causes the knee to twist or hyperextend. Such an injury most often occurs in sports that involve abrupt stops and changes in direction, such as tennis, football, soccer and basketball. It may also occur as a result of an automobile or skiing accident. Many ACL ligament tears also result from commonplace accidents like falling off a ladder or missing a step on a staircase.

Risk Factors for an ACL Injury

Women are more likely to experience an ACL tear than men, even when they are engaging in the same activities. This is because women have a strength imbalance in their thighs, with the quadriceps, the muscles at the front of the thigh, being more powerful than the hamstrings, the muscles at the back.

Symptoms of an ACL Injury

Signs of an ACL injury are difficult to ignore. These signs include:

  • Popping sound as the ligament tears
  • Immediate pain, swelling and instability
  • Increasing swelling and pain following the injury
  • Limited range of motion of the knee
  • Tenderness at the site
  • Inability to walk

Patients who are suspected of having ACL injuries should obtain medical attention immediately to avoid further joint damage.

Diagnosis of an ACL Injury

An ACL injury can frequently be diagnosed by physical examination alone. When the ACL has torn, the physician can frequently feel the increased movement of the tibia upon the femur during the physical examination. There may be significant swelling of the knee as well if the injury has occurred recently. To confirm the diagnosis of ACL injury, X-rays or MRI exam may be ordered by your physician.

Treatment for an ACL Injury

Patients who suffer ACL injuries must use crutches and possibly knee braces during the early stages of recovery after the injury. The knee may feel weak and unstable during walking, thus crutches will provide support and balance. Depending on the severity of the injury, surgery may or may not be necessary. While not all ACL injuries require surgery, leaving the ligament torn or damaged puts the patient at risk for recurring episodes of knee instability. It may also increase the likelihood of developing tissue damage or arthritis over time. For athletes who want to return to high-risk sports, surgical reconstruction is usually necessary.

ACL Ligament tears cannot be repaired by simple reattachment. When the ACL tears, there is not much tissue left to work with. Thus, ACL surgery is typically call ACL Reconstruction, meaning a new ACL must be built. This requires the use of a graft. A graft is a piece of tissue from either the patient’s own body (Autograft) or cadaver graft (Allograft). There are risks and benefits of both graft choices that your surgeon will discuss with you.

Physical therapy is always necessary to restore strength, function and stability to the knee, whether or not the patient undergoes surgery.

Anterior Cruciate Ligament Reconstruction

The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments in the knee. Running diagonally through the middle of the joint, the ACL works in conjunction with three other ligaments to connect the femur (upper leg bone) to the tibia (the larger of the two lower leg bones). ACL injuries occur most commonly in athletes as a result of direct contact or an awkward fall. About half of ACL injuries are also accompanied by damage to the meniscus, cartilage, bone or other ligaments in the knee, any of which may complicate the repair process.

The ACL Reconstruction Procedure

ACL reconstruction is usually not performed until several weeks after the injury, when swelling and inflammation have been reduced. This will reduce the risk of stiffness after the surgery. In most cases, an ACL reconstruction is necessary because there has been complete tearing of the ligament. Simply reconnecting the torn ends of the ACL will not repair it. The torn ligament has to be completely removed and replaced with a reconstruction procedure using a graft.

Most commonly, the graft used is an autograft, harvested from patient’s own body, such as the tendon of the kneecap (patellar tendon) or the hamstring tendons. In other procedures, allograft tissue, taken from a donor is used. The graft is secured to the femur bone and tibia bone with a button or screw. This procedure is performed under general anesthesia on an outpatient basis.

Benefits of Arthroscopic ACL Reconstruction

This procedure can be performed using arthroscopic techniques, which involve creating a few small incisions in the knee, into which a camera and tiny surgical instruments are inserted. Saline is injected into the knee to allow for more operating space. The surgeon performs the reconstruction while viewing the interior of the knee on a video monitor for more precise results. Arthroscopy offers patients a less invasive procedure with less scarring, less pain, less bleeding and a shorter recovery time.

Risks of ACL Reconstruction Surgery

Although considered a very safe procedure, there are certain risks associated with ACL reconstruction surgery, including graft failure, postoperative stiffness, continued instability, or post traumatic arthritis, to name a few. The risks associated with any surgical procedure, such as infection, blood clots, excessive bleeding, breathing difficulties, and adverse reactions to medication or anesthesia also apply.

Recovery from ACL Reconstruction Surgery

Following ACL reconstruction surgery, patients can return home after a few hours of medical observation. Patients will likely experience pain, bruising and swelling after surgery, which can be managed through prescription pain medication. Individual recovery varies depending on the type of procedure performed and the condition of the individual patient.

Physical therapy begins right after surgery, and normally continues for several months to help patients return to activity with their reconstructed knee. In order to achieve the most effective results from surgery, patients must commit to a long-term rehabilitation program. The ACL surgical reconstruction is typically successful, providing long-term stability of the knee joint. After completion, most patients experience effective pain relief and improved knee function.

More Information

Rotator Cuff Injuries

Four muscles in the shoulder that when injured or damaged can lead to sleepless nights, pain, and weakness.

The most common ways of injury to the rotator cuff are trauma, such as a fall on the outstretched hand, repetitive overload to the tendon by activity, or bone spurs cutting into the tendon.

Symptoms commonly begin with pain over the upper arm that is worse with reaching overhead, lying on your side, reaching behind your back, and weakness.

The rotator cuff has a very limited capacity to heal on its own and therefore treatment is often required to improve symptoms. This usually begins with a short period of rest, followed by a rehabilitation program focused on mobility, and strength to improve function. Steroid injection can be used if significant inflammation is present and interferes with the ability to engage in the exercise program. Two thirds of patients will improve with these modalities alone, and thus this is the first phase of treatment.

If symptoms persist, MRI is utilized to evaluate the rotator cuff for tears. Most commonly injured is the supraspinatus tendon. This is the muscle that allows you to put on a jacket, reach into the kitchen cabinet and get out the dishes, put a gallon of milk in the refrigerator, or pour a pot of coffee. Because the tendon is spring loaded, full tears commonly separate or retract. The more the retraction, the more serious the tear. If these tears are not addressed, atrophy will ensue and the tears will frequently get larger over time.

Surgical repair is performed arthroscopically and consists of stretching the tendon back out to it’s attachment point and repairing it back to the humerus greater tuberosity that it pulled off from. Traditionally, the shoulder was immobilized in a sling for up to 6 weeks before starting physical therapy to protect the repair. The downside of this approach was a high rate of postop stiffness, called frozen shoulder. We pioneered an accelerated rehab program for rotator cuff 25 years ago that reduced this immobilization down to just 5 days and actually lowered to postop stiffness rate.

Quality of the rotator cuff tissue has been a major determinant of success of the surgery, as well as the recurrent tear rate. The larger the tear and degree of separation, the higher the recurrent tear rate – that can approach 50 percent!

Innovation in rotator cuff surgery revolves around the use of biologics to reduce the risk of recurrent tears. CuffMend is an acellular, dermal allograft that is placed upon the repair to effectively double the thickness of an atrophic tendon and reduce the risk of recurrent tears. We have been effectively utilizing this technology over the past 2 years with great success to enhance patient outcomes for the most serious tears.

We remain committed to utilizing the best technology to remain innovators in rotator cuff surgery.