Knee
> ACL
Tear > Treatments
Reconstruction: Bone-Patellar Tendon-Bone
Autograft or Allograft
Preparing for Surgery
If you and your doctor have
decided on a patellar tendon reconstruction of your
torn ACL (anterior cruciate ligament), the decisions
you make and the actions you take before your surgery
can be every bit as important as the procedure itself
in ensuring a healthy recovery.
Make
sure you have received any equipment you will need when
you get home from the hospital. This may include a knee
brace, crutches, ice packs or coolers, or a continuous
passive motion (CPM) machine. You should receive prescriptions
for any of these from your doctor when your surgery
is scheduled.
Understand
the potential risks and benefits of ACL reconstruction
surgery, and ask your surgeon any questions that will
help you better understand the procedure. It can also
help to talk to someone else who has undergone the same
surgery.
Any
physical problems, such as a fever or infection, should
be reported to your surgeon, and you should notify your
surgeon of any medication you are taking.
If
possible, practice walking with your crutches in case
you need to use them after surgery.
Getting
a second opinion from a surgeon who is as qualified
as the surgeon who gave the initial diagnosis is advisable
in any case.
To
check if the orthopedist performing the surgery is board-certified
or eligible, which can be determined by calling the
American Board of Orthopaedic Surgery at 919-929-7103.
Day of surgery
At most medical centers, you will go to "patient
admissions" to check in for your patellar tendon
reconstruction of your torn ACL. If your surgery is
going to be inpatient, there may be a separate department,
so be sure to ask your doctor. After you have checked
in to the hospital or clinic, you will go to a holding
area where the final preparations are made. The paperwork
is completed and your knee area may be shaved (this
is not always necessary). You will wear a hospital gown
and remove all of your jewelry. You will meet the anesthesiologist
or nurse anesthetist (a nurse who has done graduate
training to provide anesthesia under the supervision
of an anesthesiologist). Then, you will walk or ride
on a stretcher to the operating room. Most patients
are not sedated until they go into the operating room.
Here are some important steps to remember for the day
of your surgery:
You
will probably be told not to eat or drink anything after
midnight on the night before your surgery. This will
reduce the risk of vomiting while you are under general
anesthesia.
You
may be discharged the same day as the surgery, but you
may stay overnight. Make arrangements for someone to
drive you home when you are released.
Wear
a loose pair of pants or other clothing that will fit
comfortably over your knee bandage when you leave the
hospital.
Take
it easy. Keeping a good frame of mind can help ease
any nerves or anxiety about undergoing surgery. Distractions
such as reading, watching television, chatting with
visitors, or talking on the telephone can also help.
The ACL is rebuilt using a graft from
the patellar tendon and typically takes two to two-and-a-half
hours. An autograft is a graft taken from the patient.
An allograft is taken from a cadaver. Consult your physician
about the advantages and disadvantages to each type
of graft.
General
anesthesia is typically used for surgery, though in
some cases a spinal or epidural anesthetic is used.
The anesthesiologist will administer the anesthesia
to put you to sleep once you are in the operating room.
The
surgeon makes an incision between two and three inches
long and a graft, called an autograft, is taken from
the middle portion of the patellar tendon, which is
the ligament that connects the kneecap (patella) to
the lower leg bone (tibia).
If
an allograft is used, there will be no need to cut and
remove part of the patellar tendon.
The
surgeon uses an arthroscope to see inside the knee and
small instruments to rebuild the ACL. The graft, which
will become the new ACL, is attached to the upper leg
bone (femur) and inserted to the lower leg bone through
holes that are drilled.
Metal
screws are put in place to hold the tendon in place
until it becomes permanently attached to the bone. The
screws usually are not removed unless tenderness develops
later on. Incisions are sewn up and the patient is taken
to the recovery room.
Following ACL reconstruction surgery,
you usually stay in the recovery room for at least two
hours while the anesthetic wears off. You will be given
adequate pain medicine, either orally or through an
IV (intravenous) line. At the time of your discharge,
you will be given instructions for what to do over the
next couple of days. In addition, you will be given
an appointment to return to see your physician and a
prescription for pain medicine. Your knee will be bandaged
and may have ice on it. There will likely be pain, and
you can expect to be given pain medication as needed.
Be sure to ask for medication as soon as you feel pain
coming on, because pain medication works best on pain
that is building rather than on pain that is already
present. The nurses will not give you more than your
doctor has prescribed and what is considered to be safe.
You should try to move your feet while you are in the
recovery room to improve circulation. Your temperature,
blood pressure, and heartbeat will be monitored by a
nurse, who, with the assistance of the doctor, will
determine when you are ready to leave the hospital or,
if necessary, be admitted for an overnight stay. It
is likely that you will be able to bear some weight
on your leg, but your surgeon may suggest that you use
crutches or a cane for between two days and three weeks.
Within two weeks, the majority of patients should be
able to walk carefully without crutches. As soon as
you are fully awakened, you are usually allowed to go
home. You will probably be unable to drive a car, so
be sure to have arranged a ride home.
After ACL reconstruction surgery,
some patients remain in the hospital for as long as
24 hours. As soon as possible after surgery is completed,
you will begin doing continuous passive motion exercises
while in bed. Your leg will be flexed and extended to
keep the knee joint from becoming stiff. This may be
done using a continuous passive motion (CPM) machine.
The CPM is attached to your bed and then your leg is
placed in it. When turned on, it takes your leg through
a continuous range of motion. There will likely be pain,
and you can expect to be given pain medication as needed.
Be sure to ask for medication as soon as you feel pain
coming on, because pain medication works best on pain
that is building rather than on pain that is already
present. The nurses will not give you more than your
doctor has prescribed and what is considered to be safe.
Ice also helps control pain and swelling.
Your rehabilitation program begins
the moment you wake up in the recovery room and continues
at home, to restore strength and range of motion to
your knee. Here is what you can expect and how you can
cope during the first days after surgery:
You
will likely feel pain or discomfort for the first few
days. Take pain medications as your doctor advises.
These could be over-the-counter painkillers, such as
ibuprofen or acetaminophen, or stronger, prescription
narcotic drugs.
As
much as possible, keep your knee elevated above heart
level to reduce swelling and pain. Icing your knee for
20 or 30 minutes two or three times a day during the
first two days after surgery also will reduce pain.
Ask
your doctor about when it will be safe for you to shower.
The
dressing on your knee is usually removed a day after
surgery, during the first follow-up visit.
Within
a week after surgery, most patients are able to lift
their leg without assistance while lying on their back.
By the end of the second or third week, they normally
are able to walk without crutches.
As
soon as possible after surgery, you should begin doing
exercises using a continuous passive motion (CPM) machine
while in bed. Your doctor can arrange to get you a CPM
machine, which helps flex and extend the leg and prevents
the joint from becoming stiff due to inactivity.
Some
people may experience night sweats and a fever of up
to 101 degrees during the first two or three days after
surgery. This is usually nothing to worry about. Your
physician may suggest acetaminophen to bring the fever
down.
Your physician may prescribe visits
to a physical therapist to begin supervised strengthening
exercises as soon as possible after your ACL reconstruction.
Recovery from a torn ACL takes an average of between
four and six months with 45- to 60-minute exercise sessions
three days a week. Though everyone's rehab program is
slightly different, physical therapy for a torn ACL
follows a general pattern. The first three weeks are
usually spent restoring a full range of motion to your
knee and recovering to the point of being able to walk
without crutches. Movement may initially be painful,
but it is important to not allow your knee to stiffen.
Rehab progresses to resistive exercises to strengthen
muscles around the knee. During this time, you should
be able to resume functional activities like stair climbing,
single leg support, swimming, and driving. After about
three months, the emphasis will change from strengthening
to functional training, as you begin exercises - specifically
geared for your activities and lifestyle - to regain
balance and control over your body. These may include
more vigorous warmups on a stationary bike, elliptical
trainer, or treadmill. You should be able to return
to normal activities after about four months. Physicians
usually suggest that you continue strength training
even after your knee has been rehabilitated. Your doctor
or therapist will likely check your knee for strength,
endurance, and stability. The result of this evaluation
will determine when you can return to sports or other
activities.
Prevention
Strengthening the hamstrings and quadriceps muscles
may help prevent further knee injury. The more aggressive
and dedicated you are during rehab, the better chance
you have of a stable, pain-free knee. After up to six
months of rehab, your knee may feel strong but your
ACL may not stabilize your knee as well as it did before
the injury. Many of the exercises and activities that
are popular for fitness put stress on your knees. To
prevent further knee injuries it is important to learn
knee-sparing exercise techniques by dividing your activities
into three components:
Daily
living - the average person takes between 12,000 and
15,000 steps a day, exerting a force between two and
five times your body weight on your knees. After a knee
injury, take it easy on your knees during the day whenever
possible to save them for activities and exercise. Avoid
stairs when there is an elevator, take the shortest
path when walking, and consider wearing athletic shoes
designed to absorb shock.
Muscle
strengthening/conditioning - activities themselves are
not a substitute for conditioning. It is essential to
adhere to the muscle strengthening program you learned
in rehab throughout the remainder of your life. The
best strengthening programs are low-impact and non-weight-bearing,
like stationary bikes and certain weightlifting programs,
so that the knees do not have to absorb shock.
Recreation
- your sport or activity of choice helps maintain mental
and physical well-being, but it is not a conditioning
program. Sports that require twisting and quick direction
changes put great strain on your knee.
A small amount of pain is normal during
physical activity, but if you feel so much pain in your
knee to warrant taking a painkiller before an activity,
you should consider cutting back or stopping. Do not
play through the pain after an ACL injury - it may be
a sign that your activity is putting too much stress
on your knee.
BRACES
No evidence has shown that braces prevent injuries,
meaning they are not a substitute for increasing your
muscle strength. Always consult your physician before
buying or using a knee brace.
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