Health & Exercise Forum

Guest Columnist: Janet Caputo, PT, DPT, OCS

Part 2 of 4

If your orthopaedic surgeon suspects an ACL tear, he/she will order an MRI (i.e. magnetic resonance imaging) to confirm his diagnosis.  The MRI results may also reveal damage to other critical structures in your knee such as the medial or lateral collateral ligaments on the side of the knee or meniscus (cartilage) shock absorbers between the bones.  Your surgeon will discuss your treatment options which typically depend on your age, activity level, degree of knee instability, and if other structures have been injured.

If you are young and athletic, or have a physically demanding profession, the knee instability from your torn ACL will interfere with the performance of your sport, recreational, or occupational activity, because your knee will constantly buckle.  This degree of knee instability is not only a safety hazard, but may also cause further damage to your knee joint resulting in the development of premature arthritis. Consequently, your surgeon will recommend surgery.  Current techniques for ACL reconstruction are very successful in restoring knee stability, but the rehabilitation following surgery requires many weeks to months of time, commitment, and hard work to achieve full, optimal function of your knee. If you are older and more sedentary, or willing to avoid activities that place a high demand on your knee (e.g. basketball, soccer, racquetball), your surgeon may recommend a more conservative route.  Individuals who are not surgical candidates or who opt not to have surgery will be required to perform exercises that emphasize strengthening and joint control (i.e. proprioceptive exercises).

Your surgeon may also recommend a functional knee brace which provides artificial support to your ligament-deficient knee to prevent your knee from buckling and to afford you pain-free performance of your activity. This is often worn before surgery and sometimes 4-6 weeks after surgery for protection.

If your surgeon recommends reconstruction, he/she will most likely prescribe several weeks of pre-operative physical therapy to not only reduce the swelling in your knee, but also restore your knee joint motion and normal walking pattern.  This pre-operative phase may require two weeks to two months, depending on how your knee responds to the initial injury.

Several ACL reconstructions are available and typically your surgeon will recommend the technique that is best for your individual needs. Currently, ACL reconstruction is performed arthroscopically (with a scope) and considered a minimally invasive procedure which usually does not require an overnight stay in the hospital. During arthroscopic ACL reconstruction, your surgeon makes two small incisions into your knee joint: (1) one to place his arthroscope, which is a small camera to view the inside of your knee, and (2) the other to insert the surgical instruments that he will use to reconstruct your ACL.

Several arthroscopic options are currently available to reconstruct your ACL.  Each option uses a tissue “graft” to substitute for your torn ACL.  Your surgeon may recommend using an autograft (your tissue) or an allograft (donor tissue).  Each option has its own advantages and disadvantages, and you should discuss any questions or concerns with your surgeon.  Below is a brief outline of the available operative procedures for arthroscopic ACL reconstruction:

• Patellar tendon graft procedure: Considered the Gold Standard, this procedure uses the middle third of your patellar tendon (the tendon just below your knee-cap).  It is a bone-tendon-bone graft because the surgeon excises the middle one-third of your patellar tendon together with two pieces of bone on either end (i.e. a piece of your knee-cap [patella] and a piece of your shin bone [tibia].  Although the fixation is very strong, your normal patellar tendon has been altered, and you may experience discomfort at the front of your knee and with kneeling and descending stairs.  However, with time and appropriate post-operative rehabilitation, these symptoms should resolve.
• Hamstring graft procedure: Your surgeon uses either your semitendinosus tendon (one of your hamstring tendons) or your gracilis tendon (a tendon on the inside of your knee) to reconstruct your ACL.  If your bones are still growing, this method is a good choice.  However, healing time is prolonged with this type of graft and you may permanently lose 10% of your hamstring strength.
• Allograft procedure: This method uses a donor tissue (tendon from a cadaver - deceased person) to reconstruct your ACL. Typically, you will experience less post-operative pain with this procedure, but there is a very small risk of contracting a serious infection from the donor tissue (e.g. HIV) and a national shortage of allografts exists due to high demand and a low supply of suitable, qualified donors.

Join us next week when we will discuss the rehabilitation process following ACL reconstruction.

Join us next week to discuss rehabilitation after ACL injury.

Visit your doctor regularly and listen to your body.

CONTRIBUTING AUTHOR: Janet Caputo, PT, DPT, OCS is clinical director of physical therapy at Mackarey & Mackarey Physical Therapy Consultants, LLC in downtown Scranton where she practices orthopedic and neurological physical therapy.

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in the Scranton Times-Tribune. Next week read: Part III of IV on ACL injuries.

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice in Scranton, PA. He is an associate clinical professor of medicine at The Commonwealth Medical College.