Background
Dr Vertullo has a special interest in ACL reconstruction, having performed over three thousand on the gold coast since returning from fellowship training in North America.
ACLR is an operation to place a new ACL graft into the knee, to replace a torn ligament. The graft is usually made from one or two hamstring tendons in place of the torn ligament. While ACL tears are a very common injury, fortunately the results from surgical reconstruction are very good.
How is it Done ?
Via keyhole incisions, under arthroscopic visualization, two sockets or tunnels are created in the femur and tibia with the new graft threaded into place between the sockets. The graft is held in place with a metal button on the femur and a plastic screw on the tibia. At the same time, any meniscal damage is either repaired, left alone or shaved depending on the pattern of meniscal injury. Other surgery can be required to fix other ligaments or chondral damage.
BEFORE YOUR SURGERY
Try to regain your range of motion prior to the surgery. Some patients with a high grade medial ligament injury may need a brace prior to ACLR surgery to allow it to heal. Avoid shaving your own leg or wearing knee sleeves as they cause pimples. If you have a pimple around the knee or any break in the skin notify Dr Vertullo’s rooms ASAP as your surgery will have to be postponed.
WHILE IN HOSPITAL
Be involved in your physio and pain medication decisions. Pain control is essential to achieve a good outcome. It is vital not to fall over after surgery to avoid wound damage, particularly on wet tiles.
What are my Graft Choices ?
Currently, hamstring grafts are the most popular graft choice as they offer the advantages of minimal pain, minimal side effects & good knee stability. The main downside is some patient suffer some knee hamstring weakness afterwards. Hamstring grafts can be 4 strand, 5 strand or 6 strand depending on the patient's size and shape. Dr Vertullo has been performing 5 and 6 strand ACLR for over a decade.
Up until approximately ten or fifteen years ago, most patients received the middle third of their patellar tendon as a graft. Most knee surgeons around the world have moved moving away from using this graft option as it can cause more stiffness and higher rates of anterior knee pain than the other alternatives. However, occasionally it is used in revision situations or where the hamstrings are used as for another graft.
There is an alternative option of an artificial graft made out of polyester, called a LARS. Recently this device has been avoided for use in intra-articular reconstructions due to concerns over long-term outcomes.
DURING RECOVERY
Rest, Ice and Elevation is important for the first week. If you experience increasing pain, swelling or wound redness etc seek rec. For the first few days or week you will be in a splint, but you can put full weight on the knee. During this week, you can start straightening your knee a few times per day. After one week, the brace comes off and rIding an exercise bike will improve your outcome and increase flexibility,
AFTER RECOVERY
It will take over 9 months for the graft to become a living part of you. The graft acts as a scaffold and slowly the body turns the hamstring graft into a living part of you.
Some Common Questions
Q: Why do I need an anterior cruciate ligament reconstruction?
There are two types of patients for whom anterior cruciate ligament reconstruction is recommended:
Group One - Active patients with an acute, i.e. recent anterior cruciate ligament rupture with or without simultaneous meniscal cartilage damage.
Group Two – Patients who have torn their anterior cruciate ligament at some stage in the past and have either gone on to develop ongoing feelings of instability or a meniscal cartilage tear.
If patients are older, less active and with either no feelings of instability or no cartilage damage, the surgery is undertaken on a case by case basis.
Q :What are the benefits of having my anterior cruciate ligament reconstructed?
The main aim is to prevent buckling or pivoting episodes of the knee which often go on to cause medial meniscal cartilage damage. If a patient tears their medial meniscus and loses it, they have a very high rate of osteoarthritis at 10 to 20 years post injury. If a patient doesn’t damage their meniscal cartilage, irrespective of what has been undertaken to the anterior cruciate ligament, they do well long-term . The main reason to have the anterior cruciate ligament reconstruction is to protect the knee from arthritis and knee replacement longer term by preventing meniscal cartilage tearing.
Q: Can I walk after the surgery and do I need crutches?
To prevent patients stumbling or falling post-surgery, a brace and crutches is used for a few days after surgery. At one week post surgery, physiotherapy is commenced.
Q: When can I return to work?
Most patients can return to work utilizing the following guide:
School/university students can usually return at one to two weeks post surgery.
Office workers can usually return at two to three weeks post surgery, depending on their transport requirements.
Heavy manual labourers or tradesman can usually return to work by six weeks but in a suitable duties capacity with expectations of full duties at three months.
Patients who work in very high demand activities such as police officers, roof tilers, merchant seaman, firefighters, armed forces personnel etc often can’t return to work until three months post surgery.
Q: When can I return to sport or other activity?
Most patients are able to return to pivoting sports at eight to nine months. Patients can ride a bike within a few weeks of surgery and most patients can go back and play golf at eight weeks and go back surfing at three or four months. You can drive once you are out of the brace and safely controlling the vehicle.
The restriction on the pivoting activity is because this is the prime stress that leads to stretching out of the anterior cruciate ligament graft. Activities that are also precluded would include touch football, netball, wake boarding, skiing etc.
Q: What do I have to be careful of after the surgery?
As the graft is a scaffold and your body grows into it over the nine months, slipping over on wet tiles is a prime cause of graft injury before it heals.
Post surgery you should notify immediately if you notice any increasing pain or swelling, either in the knee which could be a sign of infection or in the calf which could be a sign of a deep venous thrombosis.
In general, if you are getting better every day, the swelling is reducing and you are able to slowly increase your activities, then your post operative recovery is proceeding as normal.
Q: What are the complications of this surgery?
Dr Vertullo has invented a technique of infection prevention by soaking the anterior cruciate ligament graft intra operatively with antibiotics. This has reduced the infection rate from approximately 1% down to 0% over the last 1,000 anterior cruciate ligament reconstructions he has undertaken. Hence, while infection can occur, it is much less likely using this technique.
Other complications can include thrombosis in the leg, known as a deep venous thrombosis. You will be given a heparin injection while in hospital and then you will be asked to take low dose Aspirin, of 100 mg per day for three weeks after the surgery to decrease the risk of blood clots on the lungs and legs.
In addition, some patients notice numbness around their scars. Usually, if this occurs it is limited to the top end of the calf and it will decrease in time. Occasionally, however, patients always have a small patch of numbness around the wound and sometimes it never completely recovers normal sensation around the wound.
There is a 5% chance of needing a repeat arthroscopy either because the patient gets too much scarring over the graft, known as a Cyclops lesion or a meniscal repair fails. A Cyclops lesion is a lump of scar tissue prevents the knee from straightening properly and patients get a clunking sensation when they attempt to do so. If you have a meniscal repair simultaneously to the surgery, 80% of these heal spontaneously but 20% fail to do so and hence these patients need repeat arthroscopy because of meniscal tearing or non healing.
Very rare complications would include injuries to nerves and arteries.
When can I leave hospital ? Usually the same or next day.
What size scars will I have ?
You will have two 5mm incisions either side of your patella tendon, with a 3cm incision to harvest the hamstring just to the inside of your top of your tibia.
Will I need a Catheter in My Bladder or a Drain in My Knee ?
No