ACL Surgery Top 5 Questions

 

Anterior cruciate ligament (ACL) reconstruction surgery is one of the most common operations I perform. While everyone has their own unique questions and concerns about surgery, over the years, these are the top 5 questions I consistently hear people ask-

When will I be able to play sports again?

Returning to sport requires ligament healing, muscle strengthening, and reestablishing neuromuscular coordination. The rehabilitation after ACL reconstruction is long, grueling, and often harder than the actual surgery itself. Clearance for sports participation can be expected about 6-9 months after surgery. Improvement in knee function continues for up to a year after surgery with increased sports participation.

The studies show return to sport occurs in about 82-95% of patients. Return to preinjury level of participation is reported in about 63%. Fear of re-injury is the most common reason cited for a reduction in or cessation of sports participation. Approximately 85-90% of patients achieve normal or nearly normal knee function when assessed postoperatively using objective outcome instruments such as the International Knee Documentation Committee knee evaluation form.

Robert Griffin III, ACL Tear in spite of brace

Will I have to wear a brace after surgery?

No. Historically, many surgeons would prescribe functional braces after an ACL surgery. Recent studies have clearly established however that a brace does not reduce ACL re-tear rate. Some patients may feel a greater sense of security by wearing one, but it is certainly not necessary.

Custom ACL functional braces fitted to your leg can be expensive (upwards of $1,000). If you gain or lose muscle mass, these braces must be re-fit to your knee. Wearing the brace can be cumbersome and often those that do get them report eventually growing tired of wearing them. Furthermore, athletes in sports that demand agility and speed often do not like the restriction in their motion.

Simply put, if an ACL brace effective enough to prevent ACL injury existed, you can bet every single athlete at the professional level would be donning one.

What kind of graft should I use for my ACL reconstruction?

ACL reconstruction can be performed with a variety of different tissue sources or grafts. The best graft choice for you is an individual consideration, but certain attributes make certain graft choices better than others. There are 2 broad categories of graft types- ones derived from your own body (autografts) and ones derived from a cadaver (allografts).

Historically, allografts were more commonly used. Recently however, large studies have shown a slightly higher rate of ACL re-tear (23%) when using allograft tissue compared to autograft tissue (5%). The most common allografts available include patellar tendon, hamstring tendons, and achilles tendon. Allografts do not produce an immune reaction like other donated tissues. Using allograft spares the patient the discomfort associated with a graft harvest. Without a graft harvest, surgery can be performed with smaller incisions. Though minimal, disease transmission can occur (HIV < 1:1 million), and depending on the tissue preparation technique used the structural integrity of the graft may be harmed while processing.

My preferred graft source is autograft. The two most commonly used autograft sources are the patellar tendon and hamstring tendons. There are surgeons that strongly prefer patellar tendon graft and others that strongly prefer hamstring tendons. There is some evidence suggesting the patellar tendon may have a lower rate of failure compared to hamstring tendons, but the difference is minimal. Patellar tendon graft is often harvested with bone on its ends. This may lead to better and faster healing of the bone ends within the bone tunnels the graft is placed in. Harvest of the patellar tendon however in some patients can produce anterior knee pain. Masonry workers, construction workers, or others that need to kneel may find this problematic. There is also a low risk of patella fracture with patellar tendon graft use. Using hamstring autograft avoids morbidity associated with the patellar tendon use, and does not increase the risk of anterior knee pain. Hamstring may be more useful in petite patients too with restrictively small patellar tendons.

Learn more about ACL reconstruction surgery and the type of grafts available for ACL reconstruction.

How much pain will I have after surgery?

Pain is a subjective experience that varies dramatically from person to person. However, as a semi-elective procedure, we can plan for the pain after ACL surgery and using multiple modern modalities make the surgery a much more manageable experience. First and foremost, before the surgery is even planned there is an emphasis on controlling swelling and restoring motion in the injured knee. Allowing the knee and surrounding soft tissues to recover from the initial trauma of the injury makes it easier to endure the swelling and traumatization introduced by a surgery. On the day of surgery we pre-medicate and use an analgesic nerve block to reduce the sensitivity of your sensory nerves and pain receptors before we even make an incision. Our anesthesia team uses catheters that continuously infuse numbing medication around the major nerves in the operative leg. After surgery we provide strong anti-inflammatory and pain medication to address the pain as the numbing medication wears off. We take into account your sensitivity of these drugs to optimize the dosing. While we cannot eliminate all the pain associated with surgery, with this proactive approach to managing pain our patients have consistently reported a more pleasant experience than they were expecting after surgery.

When can I go back to work after surgery?

This depends largely on the demands of your particular job. The first 48 hours after surgery we recommend patients minimize their activity. Due to the effects of anesthesia on the body, after surgery it is normal to feel exhausted and weak. Management of pain often requires the use of narcotic pain medications for the first 1-2 weeks after surgery. These medications can make you drowsy and impair judgement. Once your pain is controlled and you no longer require narcotic pain medications consistently during the day, you will be safe to resume sedentary desk work, or attend classes in school. Some patients have been able to telework as early as 3-4 days after surgery from home; however, this is the exception rather than the norm. For students we recommend taking at least 4-6 days off from school after surgery. For those that are working we recommend taking 7-10 days off from work. If you have a physically demanding job, depending on the demands of your occupation, when it is safe to return is determined on a case by case basis. If your employer does not offer a light duty alternative for you, you may need to apply for short term disability with your employer.

Learn more about ACL reconstruction surgery.

Anterior cruciate ligament (ACL) reconstruction surgery is one of the most common operations I perform. While everyone has their own unique questions and concerns about surgery, over the years, these are the top 5 questions I consistently hear people ask-

When will I be able to play sports again?

Returning to sport requires ligament healing, muscle strengthening, and reestablishing neuromuscular coordination. The rehabilitation after ACL reconstruction is long, grueling, and often harder than the actual surgery itself. Clearance for sports participation can be expected about 6-9 months after surgery. Improvement in knee function continues for up to a year after surgery with increased sports participation.

The studies show return to sport occurs in about 82-95% of patients. Return to preinjury level of participation is reported in about 63%. Fear of re-injury is the most common reason cited for a reduction in or cessation of sports participation. Approximately 85-90% of patients achieve normal or nearly normal knee function when assessed postoperatively using objective outcome instruments such as the International Knee Documentation Committee knee evaluation form.

Will I have to wear a brace after surgery?

Robert Griffin III, ACL Tear in spite of brace

No. Historically, many surgeons would prescribe functional braces after an ACL surgery. Recent studies have clearly established however that a brace does not reduce ACL re-tear rate. Some patients may feel a greater sense of security by wearing one, but it is certainly not necessary.

Custom ACL functional braces fitted to your leg can be expensive (upwards of $1,000). If you gain or lose muscle mass, these braces must be re-fit to your knee. Wearing the brace can be cumbersome and often those that do get them report eventually growing tired of wearing them. Furthermore, athletes in sports that demand agility and speed often do not like the restriction in their motion.

Simply put, if an ACL brace effective enough to prevent ACL injury existed, you can bet every single athlete at the professional level would be donning one.

What kind of graft should I use for my ACL reconstruction?

ACL reconstruction can be performed with a variety of different tissue sources or grafts. The best graft choice for you is an individual consideration, but certain attributes make certain graft choices better than others. There are 2 broad categories of graft types- ones derived from your own body (autografts) and ones derived from a cadaver (allografts).

Historically, allografts were more commonly used. Recently however, large studies have shown a slightly higher rate of ACL re-tear (23%) when using allograft tissue compared to autograft tissue (5%). The most common allografts available include patellar tendon, hamstring tendons, and achilles tendon. Allografts do not produce an immune reaction like other donated tissues. Using allograft spares the patient the discomfort associated with a graft harvest. Without a graft harvest, surgery can be performed with smaller incisions. Though minimal, disease transmission can occur (HIV < 1:1 million), and depending on the tissue preparation technique used the structural integrity of the graft may be harmed while processing.

My preferred graft source is autograft. The two most commonly used autograft sources are the patellar tendon and hamstring tendons. There are surgeons that strongly prefer patellar tendon graft and others that strongly prefer hamstring tendons. There is some evidence suggesting the patellar tendon may have a lower rate of failure compared to hamstring tendons, but the difference is minimal. Patellar tendon graft is often harvested with bone on its ends. This may lead to better and faster healing of the bone ends within the bone tunnels the graft is placed in. Harvest of the patellar tendon however in some patients can produce anterior knee pain. Masonry workers, construction workers, or others that need to kneel may find this problematic. There is also a low risk of patella fracture with patellar tendon graft use. Using hamstring autograft avoids morbidity associated with the patellar tendon use, and does not increase the risk of anterior knee pain. Hamstring may be more useful in petite patients too with restrictively small patellar tendons.

Learn more about ACL reconstruction surgery and the type of grafts available for ACL reconstruction.

How much pain will I have after surgery?

Pain is a subjective experience that varies dramatically from person to person. However, as a semi-elective procedure, we can plan for the pain after ACL surgery and using multiple modern modalities make the surgery a much more manageable experience. First and foremost, before the surgery is even planned there is an emphasis on controlling swelling and restoring motion in the injured knee. Allowing the knee and surrounding soft tissues to recover from the initial trauma of the injury makes it easier to endure the swelling and traumatization introduced by a surgery. On the day of surgery we pre-medicate and use an analgesic nerve block to reduce the sensitivity of your sensory nerves and pain receptors before we even make an incision. Our anesthesia team uses catheters that continuously infuse numbing medication around the major nerves in the operative leg. After surgery we provide strong anti-inflammatory and pain medication to address the pain as the numbing medication wears off. We take into account your sensitivity of these drugs to optimize the dosing. While we cannot eliminate all the pain associated with surgery, with this proactive approach to managing pain our patients have consistently reported a more pleasant experience than they were expecting after surgery.

When can I go back to work after surgery?

This depends largely on the demands of your particular job. The first 48 hours after surgery we recommend patients minimize their activity. Due to the effects of anesthesia on the body, after surgery it is normal to feel exhausted and weak. Management of pain often requires the use of narcotic pain medications for the first 1-2 weeks after surgery. These medications can make you drowsy and impair judgement. Once your pain is controlled and you no longer require narcotic pain medications consistently during the day, you will be safe to resume sedentary desk work, or attend classes in school. Some patients have been able to telework as early as 3-4 days after surgery from home; however, this is the exception rather than the norm. For students we recommend taking at least 4-6 days off from school after surgery. For those that are working we recommend taking 7-10 days off from work. If you have a physically demanding job, depending on the demands of your occupation, when it is safe to return is determined on a case by case basis. If your employer does not offer a light duty alternative for you, you may need to apply for short term disability with your employer.

Learn more about ACL reconstruction surgery.

Sources:

These are just a few of the questions I typically hear from my patients. Feel free to ask any other burning questions below in the comments or call my office at 281-690-4678 to arrange a face to face consultation.

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