Knee Problems-Anterior
Cruciate Ligament
Anterior
Cruciate Ligament
Posterior Cruciate Ligament
Meniscus Repair
Meniscus Transplant
Total Knee Replacement
Osteotomy
Cartilage Regeneration and Arthritis
Orthopaedic Updates
Anterior Cruciate Ligament
Surgical Advances
Patients
Questions and Answers
Surgical
Advances
Over 120,000 ACL reconstructions are performed in the United States
each year. Because many people never seek a physician’s care after
they hurt their knee, it is estimated that the number of new ACL
injuries is at least double that amount. Certainly, ACL ruptures are
one of the most common serious knee injuries that occur and the
consequences can be devastating to both young and older individuals
alike.
The highly trained and experienced orthopaedic surgeons at
Cincinnati SportsMedicine and Orthopaedic Center have performed
thousands of ACL reconstructions, using all available graft
material. The results of these surgical procedures have been
reported in clinical outcome studies and published in the medical
community’s most respected publications, read by physicians
worldwide. More than 60 clinical research studies have been
conducted and reported to the medical community from our Center.
"While ACL reconstruction may appear to be a common operation, the
procedure requires highly trained and experienced surgeons to ensure
that the proper graft is selected and placed in the anatomically
correct position in the knee. An appropriate rehabilitation program
must be followed and these programs vary according to the individual
characteristics and needs of our patients. Unfortunately, we see all
too many patients referred from other surgeons after a failed ACL
reconstruction. Patients should realize that surgeon training and
experience is paramount in this operation.
Our studies have reported a 95% success rate for patellar tendon
autograft ACL reconstructions, one of the highest found in the
medical literature. In addition, less than 1% required a reoperation
for a limitation of knee motion after surgery. Our numbers speak for
themselves. That is what convinces people to come here."
Sue Barber-Westin, B.S.
Director of Clinical and Applied Research
Cincinnati Sportsmedicine Research and Education Foundation
"Our rigorous follow-up studies of patients who have ACL
reconstructions have provided some very important information to the
community. Our rehabilitation program, which was the first in the
United States to include immediate knee motion after surgery, has
resulted in one of the lowest complication rates reported in the
literature. We were the first to find that there is literally no
difference in results of this operation between men and women. We
have also found that, in patients with arthritis, ACL reconstruction
helps relieve symptoms and can be performed without aggravating the
arthritis."
Frank R. Noyes, M.D.
President
and Medical Director
Cincinnati SportsMedicine Research and Education Foundation
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Patients
Parents write us about their daughter's ACL surgery:
Dear Dr. Noyes,
With Sheri facing surgery again*, I find myself thinking of her last four years as a Clemson Soccer athlete and my thoughts turn to you. I want to thank you so much for the opportunity you had given back to her. You enabled her to compete once again at the college level.
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Sheri Bueter,
Clemson soccer
standout and ACL patient. |
I'll never forget the year after her ACL surgery, when she came
to your office for an examination for your research paper. After
examining and talking with her you told her how pleased you are with
her. She looked up at you and said "And I'm pleased with you."
That statement says it all.
Let me take a minute to tell you of Sheri's achievements since her ACL
surgery. She is Clemson's all time assist leader. Sheri was a captain her
4th and 5th year. She made all ACC and the ACC tournament team each year
following her surgery.
This year's ACC tournament was played at the Disney Sports Complex in
Orlando, Fla. Although Clemson lost in the final game, Sheri left her mark.
After the Semi-final game, Sheri was taken to the press for an interview
with the Orlando newspaper as well as FOXSS and Soccer America.
Since then, Sheri was invited and attended a camp with the Women's National
Team. She was also asked to attend the following camp with the women's
team, in January, at Orlando, Fla. As well, she was invited to play with
the NCAA division I All-star team in February, both of which she was unable
to participate in due to her injury. But, Sheri seems to be all right with
things the way they are. She is just so happy that she was able to finish
her college career with success. She graduated from Clemson this past
December and with a wedding in her near future, she can move on with her life.
I hope in some small way this letter shows that as parents, we are so happy
for what you have given back to our daughter. And I know Sheri feels the
same way!
Thank you so much and God Bless.
Sincerely,
Jerome C. Bueter
Loraine J. Bueter
*Sheri tore her meniscus in the championship game.
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What is the ACL?
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The anterior cruciate ligament (ACL) is one of four main ligaments, which holds the femur and tibia together. The ACLâs job is to keep the tibia from coming too far forward from the femur.
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The ACL is like a piece of rope. When it is stretched beyond its ability to work, the rope fibers tear or are torn apart. Treatment options are based on whether the ACL or "rope" is partially torn or completely torn apart.
How do I know if I've torn my ACL?
Most people have the following symptoms:
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*Swelling within a few hours of the injury
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*Loss of Motion
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Loss of ability to extend and flex the knee
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Distinctive "pop" heard
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"Giving-way" episodes. Your knee may collapse and you fall to the ground
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Pain
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Some people are able to continue their activity; some people's knees collapse and they cannot walk normally
You may also experience:
*Swelling and loss of motion are the two biggest clues pointing to a torn
ACL.
When should I see a physician?
If your symptoms last more than two days, you should seek the proper medical care; a sports medicine trained physician. If your pain and swelling are severe seek attention immediately to make sure a fracture has not occurred.
Even if you have a partial ACL tear, we recommend that everyone see a sports medicine physician who will tell you exactly what you are dealing with. Sixty percent of people who have an ACL tear also have a meniscus tear. If you have a meniscus tear your knee is probably catching or locking, indicating that the meniscus is "flipped up into the joint" preventing knee motion. |
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Why should I see a sports medicine-trained orthopaedic surgeon?
The training of an orthopaedic surgeon involves many years of undergraduate, medical school, and residency education. The specialization of sports medicine involves additional training, usually at an educational center where a fellowship year is completed. This involves advanced training in arthroscopic surgery, required in the treatment of most knee, shoulder, ankle, elbow and sports medicine-related injuries. The sports medicine-trained surgeon also has knowledge of specific rehabilitation and muscle performance issues to safely regain function and return patients to athletics. A sports medicine center combines the disciplines of physicians, physical therapists, athletic trainers, and more to totally heal all aspects of an injury.
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Will I need surgery?
There are four factors that determine the answer to that question.
The answer is "no" if:
You have a sedentary lifestyle requiring no particularly strenuous activity; then you may not need surgery. However, that does not mean you should not seek treatment. Conservative treatment does not mean no treatment. You must still be under an orthopaedic surgeon's care and go through rehabilitation to strengthen your knee. If not, you may have additional "giving-way" episodes which continue to damage the structures in the knee, causing arthritis. Ultimately we want to prevent arthritis.
The answer is an immediate "yes" if:
Your knee is locking or catching, several times daily. As we mentioned above, you may also have a meniscus tear. This is the only time you will require surgery within a few days after your injury. A meniscus tear needs to be repaired immediately if it is causing your knee to catch or lock.
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The answer is also "yes" if:
You are an active person or have a physically demanding occupation, we suggest you have your ACL repaired. We have a 95% success rate with ACL reconstructions. Advances in repair techniques and rehabilitation have made the surgery much more appealing and successful for all active individuals, not just the highly competitive athletes who were the primary candidates for ACL reconstructions 15 years ago.
Before you can have surgery, several things will need to happen:
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Knee swelling must be eliminated
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You must go through 2 to 4 weeks of rehabilitation to regain joint motion and muscle function after the injury. It is easy to lose muscle very quickly. Rehabilitation focuses teaching important exercises to regain muscle strength in addition to mental preparation for the surgery. Though an ACL reconstruction is a relatively common procedure, with more than 50,000 performed each year, it is still major surgery. The stronger your knee and attitude before surgery, the better your surgical outcome will be.
The answer is also "yes" if:
You continue to have "giving-way" episodes. Repeated instances, when your knee gives-way and you fall to the ground, indicate you have a chronic knee problem. Surgical repair of the ACL can prevent future damage to the knee joint and resulting arthritis. It can also improve your quality of life.
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What are my surgical options?
At Cincinnati Sportsmedicine, we prefer to use autograft tissue (taken from your own body) for most ACL reconstructions. There are three autograft tissue options that provide strength and viability equal to or greater than the ACL:
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Repair of a complex
meniscus tear done
with an ACL reconstruction |
Our physicians are also well-experienced with the implantation of allograft tissues (taken from a cadaver donor). We only use allograft tissues from tissue banks that are certified by the American Association of Tissue Banks and have passed FDA inspection. The allografts are irradiated to kill bacteria and many viruses. The level of irradiation (2.5 megarads) does not harm the biomechanical properties or healing capabilities of the allograft tissues. We use two types of allografts for ACL reconstruction::
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Patellar Tendon
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Achilles Tendon
Most surgeons recommend the procedure they are most comfortable with and have used the most frequently. We are fortunate at Cincinnati Sportsmedicine that we have a wide range of experience with all types of grafts and can recommend the one best suited for each individual patient.
A tremendous amount of research data exists on the outcome of each type of graft used for ACL reconstruction. In our extensive clinical studies, we have found that patellar tendon and hamstring tendon autografts have a higher success rate than allografts and that is why these are our preferred grafts for most patients. The exceptions are patients who have multiple ligaments that are ruptured and in whom autograft tissues are not available or feasible to use. Some patients who have had a prior ACL reconstruction which failed may be considered candidates for allograft reconstruction, especially if other ligaments also require surgical correction at the same time.
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What can I expect following my surgery?
Rehabilitation is an essential element or your recovery. The success of your ACL surgery is not only determined by an expert surgeon, but also by following a rigorous rehabilitation program. YOUR SURGERY MAY FAIL IF YOU DO NOT FOLLOW THE RIGHT REHABILITATION PROGRAM.
There are two rehabilitation protocols we follow.
1. Accelerated Protocol
This rehabilitation program is designed for patients who have had an ACL reconstruction and have had no other surgical procedures, such as a meniscus repair. They do not have knee arthritis or damage to their joint lining. They have a "normal" joint and are highly competitive athletes who want to return to their sport ASAP. |
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This program involves:
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Immediate motion following surgery
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Strict, immediate rehab exercises
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Limited use of crutches, for comfort only, for 3 to 4 weeks
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Possible running as early as 12 weeks after surgery*
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Full sports activity resumed as early as five months after surgery*
*Only if certain muscle strength, ligament function and symptom criteria are met.
Click here to see our detailed accelerated rehabilitation protocol.
2. Delayed Protocol
This rehabilitation program is for everyone else. If you have had other major operative procedures, in addition to your ACL repair or if arthritis was discovered during the initial diagnostic arthroscopy.
This program involves:
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Immediate motion following surgery
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Immediate rehabilitation exercises
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Crutches for 5 weeks
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Running, if desired, six months after surgery**
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Return to sports activity, if desired, eight months of rehabilitation**
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***Only if certain muscle strength, ligament function and symptom criteria are met. Patients with arthritis are usually advised to return only to light recreational activity to avoid further joint damage.
Click here to see our detailed delayed
rehabilitation protocol.
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How do I avoid complications after surgery?
The Cincinnati Sportsmedicine ACL Program has one of the lowest complication rates reported to date in the medical literature. Two Cincinnati Sportsmedicine studies, some of the medical communityâs largest on ACL complications, support our claim that our surgical techniques, followed by our rehabilitation programs are the most successful in the country. Expertise of the surgeon in understanding how to correctly place each graft, combined with the right rehabilitation program is based on a concept developed by Dr. Frank R. Noyes more than 25 years ago. The principles involve immediate knee motion, early functional use of the knee, early intervention with rehabilitation techniques if motion or strength is limited, allowing time for healing, maximizing neuromuscular training, and graduated return to high intensity sports to avoid injury.
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What if after my surgery, Iâm still having problems with my knee?
If your knee is loose and unstable, you continue to have pain, swelling, and giving-way, and you've already had your ACL reconstructed, then your surgery may have failed. ACL reconstructions fail for many reasons - fortunately, this occurs in only about 5% of patients. You should seek treatment with a center and orthopaedic surgeon highly trained and experienced with ACL revision surgery. We see patients from around the world who have had prior knee surgery and problems have occured. With our extensive experience, we have develped procedures, techniques, and rehablitation programs that are specially designed to help patients still attempt to achieve a good result.
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Should I have the surgery repeated?
Patients benefit from having the ACL reconstruction repeated to prevent further damage to the knee joint and increase their level of activity. Although we usually do not recommend in the majority of cases the return to very strenuous activities after revision surgery, most patients can return to an active lifestyle and improve their quality of life. The level of activity a patient can resume is dependent on the amount of arthritis, or joint damage, that exists; the condition of the two menisci; and the postoperative recovery in terms of restoration of muscle strength, balance, coordination, and other factors.
ACL revision surgery can be performed with either autografts or allografts. We prefer to use autografts (the patient’s own patellar tendon or quadriceps tendon) for revision surgery, as the success rates are higher than those obtained with allografts (cadaver tendons). |
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We have published two major studies on ACL revision reconstruction. We reported encouraging results in 114 knees:
It is important to note that success rates for revision surgery in terms of restoration of normal knee stability are approximately 70-80%, as compared to 95% for first-time ACL reconstruction surgery. There are complicating factors such as weakness to the knee’s "secondary" or supporting tissues which can become stretched or over-worked over time which are difficult to repair. The patient’s bone at the areas where the graft is attached on the tibia (shin bone) may be soft (called osteopenia) from arthritic damage or repeated injuries and this can effect the ability of the graft to fully incorporate and heal. In many patients, the meniscus has been previously removed and the loss of this important structure can also effect the overall stability that can be achieved through revision surgery.
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If you'd like more information regarding
ACL injuries and reconstruction,
please contact our Director of Clinical Studies, Sue Barber-Westin, at sbwestin@csmref.org.
