ACL Tear Surgery - Diagnosis & Recovery

Benefits of Arthroscopic ACL Reconstruction Surgery

Arthroscopic ACL reconstruction surgery provides various benefits, including:

• Restoration of knee function:  ACL tears significantly inhibit the functionality of the knee. ACL repair surgery is the best option to restore knee stability and function effectively. The surgery addresses the root cause of the problem. It permanently repairs the torn ACL, restoring stability to the knee and allowing the patient to return to normal activities. 
• Significant symptom relief: ACL tears can cause a variety of symptoms, including moderate to severe pain, lack of functionality, swelling, and weakness. Non-surgical treatment options are effective only in reducing the symptoms. The torn ACL is not healed through them.  Arthroscopic ACL reconstruction surgery can significantly reduce the pain, swelling, and limitations in the affected knee joint. 
• Prevention of further damage: ACL repair surgery helps in preventing damage to the cartilage and surrounding knee structures. ACL repair surgery stabilizes the knee and prevents strain and possible injury to the rest of the knee structures. 
• Cost-effective: The surgery also tends to be the most cost-effective than physical therapy, bracing, and other non-surgical treatments. 

Timeline For ACL Surgery Recovery

The timeline for healing and recovery following anterior cruciate ligament (ACL) reconstruction surgery depends on multiple factors, which encompasses everything from prior fitness level to activity goals, surgical procedure, and post-operative guidelines. However, there are a few general guidelines common to many patients. Listed below is the timeline for recovery after ACL surgery:

Weeks 1-3:

The initial three weeks after surgery are the most crucial for healing time. Be diligent toward good nutritional intake, and the use of ice to control excessive inflammation is critical to promote the healing. During this period, the body is recovering from surgery and requires an optimal environment to ensure the readiness of the muscles to make necessary strength gains. It is extremely important to  regain control of the leg muscles, especially the quadriceps (thigh) muscle, to achieve normal gait and improve strength. Strength regaining is helpful for activities like stair climbing and standing from a seated position. Improving mobility of the knee is also important to improve function and serves a secondary purpose for healing. It also helps in distributing vital nutrients to the healing tissues.

Weeks 4-6:

During this period of recovery, remodeling of the tendon replacement, or graft, occurs. If an individual uses their own tendon as a replacement for the torn anterior cruciate ligament, then the tendon must undergo remodeling. During remodeling, the tendon breaks down (or remodels) into ligamentous tissue suitable to withstand the forces required of an ACL. By the end of this recovery period, patients note a significant improvement in recovery. If no other structures were repaired in addition to the ACL, many patients may be able to walk without an assistive device or brace, provided their quad recruitment has improved sufficiently. Due to decreased inflammation, they may also regain satisfactory mobility to perform activities like bending the knee to put on pants and other physical activities.

Week 6-12:

In this phase, the knee is capable of taking greater loads, and individuals may note the considerable gains in functional strength. Patients begin working on more activity-specific strengthening and weight-bearing exercises, such as squats, ascending and descending stairs, and balancing. You can also begin biking with resistance. The muscles begin to recover their normal function, and gait becomes quite normalized. Since the 6-12 week phase involves a lot of repetitive activities, diligence during this phase is critical as patients focus on building lower extremity strength, endurance, and control to enable progression to impact exercises in preparation for return to work, sport, or other activities during the next phase.

3-6 months:

By this time period, enough healing has occurred, and the ACL has gained sufficient strength to enable patients to return to running and jumping or impact activities. Greater recovery in muscle control and stability is also typically achieved. While the ligament can be subjected to greater forces, patients usually continue to exhibit poor coordinated lower extremity function. Therefore, ensuring the exercises are executed with good form and control is imperative to avoid increased stress on the reconstructed ACL and surrounding tissues.

Training the leg to control jumping and landing properly is necessary to minimize the risk of re-injury when the patient returns to sports or recreational activities. Once sufficient lower extremity control is noted with jumping, hopping, and squatting, individuals can return to cutting activities. Ensuring good form with cutting is essential to full recovery as rotational motions such as pivoting and cutting mimic activities that are common to mechanisms of ACL injury. Often an individual will sustain an ACL tear due to poor leg stability or control during activities such as pivoting and landing from a jump, which is why a full recovery in function is essential to minimize the risk of future injury.

6-12 months:

During this period, the patient starts feeling better, and the doctor usually recommends resuming physical activities such as squatting, hopping, jumping, running, and cutting. However, the 6-month time frame is typically the earliest for patients to return to contact sports, as graft healing and recovery can take up to 12 months or more. Thus, to reduce the chance of re-injury, a person must be careful to maintain monitoring of lower extremity alignment and control while performing cutting, running, and landing.

Risk and Complications of ACL Surgery

Like any surgical procedure, ACL surgery also carries certain risks and complications, including

• Anterior knee pain: The most common complication after ACL surgery is pain around the kneecap. It usually occurs in the patient who has surgery performed with a patellar tendon graft, as this procedure involves the removal of bone from the kneecap. 
• Stiffness (arthrofibrosis): It is quite common to experience stiffness in the knee joint after an ACL injury. However, in most cases, it can be easily managed with aggressive rehabilitation. In some rare instances, a ball of scar tissue forms in the front of the knee, even despite rehabilitation. It can also lead to an inability to straighten the knee fully. 
• Instability: In some cases, after reconstruction surgery, instability of the knee occurs. It is the result of a surgical error or an undiscovered injury that occurred in or around the knee at the time of ACL tear.
• Graft stretching: When an ACL is reconstructed, the ACL is replaced by an autograft or allograft. In autograft, bone or tissue is transferred from one part of a patient’s body to another. An allograft is a transfer of bone or tissue from a donor or cadaver. In some cases, the graft used to replace a torn ACL is stretched, potentially leading to other complications like instability or graft failure.
• Ganglion cyst formation: A rare complication from ACL reconstruction surgery is the formation of a cyst within or around the graft. These cysts are usually harmless and can be routinely removed, but they can sometimes cause symptoms like Knee pain, clicking of the knee, reduced knee extension, and stiffness. 
• Growth plate injury: Bleeding at the incision site of an ACL surgery is common but can be a concern if the blood is excessive enough that it soaks through wound dressings and does not stop after pressure is applied to the area. 
• Bleeding: Bleeding at the incision site of an ACL surgery is common but can be a concern if the blood is excessive enough that it soaks through wound dressings and does not stop after pressure is applied to the area. The reason for bleeding after ACL surgery varies and is usually caused by an underlying issue. For example, in some cases, injury to an artery during surgery may cause bleeding, and surgically repairing the artery will stop the bleeding from continuing.
• Disease transmission: Infection is a rare complication but can be serious when it occurs. When the infection is inside the knee joint, there is a concern about the ACL graft becoming infected. If the infection is serious and does not get better with antibiotics, the graft may need to be surgically cleaned or removed to eliminate the infection.
• Blood clots: Following ACL surgery, blood clots can form in the thigh or calf, with the potential to break off in the bloodstream and travel to other parts of the body, such as the lungs or brain.The reason for blood clots that develop after ACL surgery is unknown, but research suggests that factors can include a personal history of blood clotting, age (over 30 years), and hypertension.
• Re-Rupture of the ACL Graft: Repeat rupture of the ACL graft is uncommon but sometimes occurs. Whenever there is a re-rupture of the graft, a surgeon should carefully assess for possible technical failures of the first surgery. Possible problems that can lead to the re-tear of the ACL include suboptimal positioning of the graft, improper tension on the graft, or failure of the fixation of the graft. 

What Does Rehabilitation For ACL Injury For Athletes Entail?

Generally, rehabilitation for ACL injuries lasts for around 4-5 weeks, but since athletes put more strain on their joints, they need longer rehabilitation periods for better movement. It also helps in preventing the recurrence of the injury. The treatment is usually performed with three goals:

• Stabilizing the joint to promote healing
• Strengthening the joint to increase the range of motion of the joint
• Increasing joint flexibility to decrease the chances of re-injury following the return to sports

Most athletes can start training for their sports about 4-6 months after the ACL surgery, but doctors usually recommend full rehabilitation before they start participating in the sports again. The rehabilitation period can be divided into the following:

• Phase 1: 3-4 months after surgery- Regain strength and improve the flexibility of the joint.
• Phase 2: 4-6 months after surgery- Low-level fitness and performance agility drills.
• Phase 3: 5-8 months after surgery- Jumping exercises.
• Phase 4: 6-9 months after surgery- Single-leg jumping exercises with sports-specific cutting.
• Phase 5: 9-12 months post-surgery- Steadily increase sports drills till the former skill is achieved while focusing on preventing re-injury.

ACL Surgery Cost in India

The cost of ACL surgery in India ranges from Rs. 1,80,000 to Rs. 2,42,000. This is the average cost of surgery, the final cost of surgery can vary depending on various factors, including

• Type of anesthesia administered
• The city of the treatment
• The general cost of hospitalization
• General fees of the surgeon
• Comorbidities such as diabetes, liver or lung disease, etc.
• Type of graft used
• Additional surgery 
• Rehabilitation and physiotherapy 
• Insurance coverage

What are the Types of ACL Surgery Grafts?

There are many variations of ACL reconstruction, each variation aims to give a patient the best functioning knee. The variability depends on what the graft, the new ligament, is made from.  In general, there are three main graft options, including

• Patellar tendon autograft

It involves harvesting the central one-third of the patellar tendon from the injured knee. The patellar tendon connects the patella, or kneecap, to the tibia or shinbone. When the graft is harvested, a small piece of bone is taken from the patella and the tibia, making it a bone-tendon-bone graft.

The graft is inserted into the knee to form a new ACL using screws, and eventually, the graft bone fuses with the surrounding bone of the femur and tibia. The advantage of a patellar tendon graft is its strong initial fixation. The patellar tendon eventually regenerates in the donor’s knee. 

• Hamstring Autograft

It is a group of tendons that connect to the hamstring muscles of the back of the thigh. When a hamstring autograft is used, two of these tendons are removed and bundled together using sutures to create a tissue graft. The hamstrings are usually taken from the leg undergoing ACL reconstruction. The major advantage of this method includes a very small incision to harvest the tendon.

The chances of risk of developing patellofemoral pain or patellar tendon rupture are quite low. Though the hamstring graft does not have as strong of fixation as the bone-to-bone fixation of the patellar tendon graft, the fixation is still very strong, and fixation methods are being improved upon all the time. Additionally, like the patellar tendon, hamstring tendons also regenerate.

• Allograft

It is taken from a cadaver donor and is also commonly used for ACL reconstruction. An allograft is not quite as strong as a patient’s own tissue. For a non-competitive athlete, an allograft can function at a very high level and allow a patient to return to their desired sports and activities. The main advantages of allografts include decreased operative time, less post-operative pain, and no need for harvesting incisions.

There is always a minuscule risk of contracting a disease from the tissue because the tissue comes from someone else. However, advancements in screening and sterilization make this risk exceedingly small. Furthermore, because these grafts are thoroughly washed and contain very little protein antigen, the risk of graft rejection is also very small. Allografts are a good option for casual athletes, athletes over 40, revision or repeat ACL surgery, and those who absolutely prefer minimally invasive surgery.

How to Find the Best Surgeon For ACL Surgery?

If you are looking for the best knee replacement surgeon in India, then you must consider the following factors before choosing one-

• Experience of the surgeon: It is one of the important factors that you should consider before choosing an orthopedic surgeon. Orthopedic surgeons deal with some serious health issues, so it is vital to consult an experienced surgeon with a good track of successful outcomes. 
• Check the patient’s review and history: Check the patient’s review before finalizing the surgeon. It helps understand the surgeon’s professionalism, bedside manner, and communication skills. In short, it gives you a rough idea about the quality of care and the success rate.
• Check the surgeon’s credentials and expertise: It is crucial to check the credentials of an orthopedic surgeon to ensure that the surgeon is up to date in his/her knowledge. It also clarifies that the surgeon has no major issues/complications in performing any treatment or surgery. Moreover, it also gives you an idea about the experience and expertise of the surgeon. 
• Consider location and convenience: Consider a surgeon who is at a reasonable driving distance to avoid any complications during the treatment procedure. Apart from quality treatment, it is important that the orthopedic surgeon is easily accessible or available to maintain quality care, especially in emergency cases.
• Research about the hospital: It is one of the important factors to consider before finalizing the surgeon. Investigate the hospital your orthopedic surgeon is associated with. It gives an idea about the medical staff, hygiene, and also the quality of care they provide. We suggest checking the patient testimonials and recovery outcomes before finalizing the surgeon.

Is ACL Tear Surgery Covered Under Insurance?

ACL tear surgery is usually covered under insurance because it is a medically necessary procedure that is typically performed to help individuals regain stability, function, and mobility in their knee joints. ACL injuries are common among athletes and active individuals and can occur due to sudden twisting or impact on the knee.

The coverage may vary depending on the specific insurance plan and the individual’s medical history and needs. It is important to check with your insurance provider to understand what is covered under your policy and what out-of-pocket expenses you may have to bear.

Research Papers for ACL Tear

• ACL TightRope® Implant Scientific Update
• FDA Provides Clearance of First-Ever Device for ACL Reconstruction in Children
• ACL Primary Repair Scientific Update
• The modern-day ACL surgeon’s armamentarium should include multiple surgical approaches including primary repair, augmentation, and reconstruction: A letter to the Editor