James M. Fox, MD Synergy Performance Health
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Anterior Cruciate Ligament - Frequently Asked Questions

What is the Anterior Cruciate Ligament?
How is the Anterior Cruciate Ligament Torn?
What are Common Symptoms of Damage to the ACL?
What are the Treatment Options?
What are the Surgical Choices?
Is the “New Tissue” a Normal Anterior Cruciate Ligament?
How Long Does it Take for the Body to Perform this “Remodeling”?
What Types of Tendons are Available?
Is One Type of Tendon Stronger than Another?
Does One Tendon Appear to Have Better Results than Another?
Why Does One Surgeon Prefer a Particular Tendon for Reconstruction?
Why May a Certain Tendon Not be Used at Times?
What Particular Problems Have Been Seen with the Different Types of Grafts?
What are Particular Risks and Problems of Using a Donor Tendon?
Are the Concerns About Virus Communication the Same as in the General Population?
What Happens Before My Surgery?
What Should I Do the Night Before Surgery?
How is the Surgical Procedure Performed?
Will I be Using a Brace and Crutches?
What are My Activities at Home?
When Can I Leave My Home?
How Do I Use My Ice Pack?
What About Medication?
When I Took My Brace Off, I Noticed There was Some Oozing on My Dressings.  Is This Normal?
If I Have Questions, Concerns, or I Do Not Seem to be Recovering, What Should I Do?
How is the Graft Held in Place?
What are Some of the Standard Risks of the Surgical Procedure?
I Have Heard that Some Special Devices Such as Cooling Machines or Range of Motion Apparatus are Needed.  Is This True?
I am Traveling to See Dr. Fox From Out of Town.  Do You Have Any Suggestions?
When Do I Begin My Rehabilitation Program?
When Can I Return to Work?


What is the Anterior Cruciate Ligament?
The anterior cruciate ligament (ACL) is a tight band of “collagen” tissue which connects the tibia or shin bone with the femur or thigh bone.  Simply stated, it prevents the shin bone from sliding forward and rotating abnormally on the femur.

How is the Anterior Cruciate Ligament Torn?
This ligament can be torn in many different ways.  The most common mechanism of injury is rotation of the upper body outward with the foot planted; the patient often feels a pop or snap within his knee.  However, various mechanisms of injury have been described by patients.  Therefore, although there are typical maneuvers that have historically caused injury, numerous exceptions exist.

At times, patients have had a history of old injuries which have seemed to heal and then become more symptomatic with time and other minor injuries.

What are Common Symptoms of Damage to the ACL?
With an acute injury, there is usually pain, swelling and an initial feeling of shifting of the shin bone on the thigh bone.  With a chronic condition, patients often complain of instability, either with sporting activities (planting and rotating) or progressing to activity of daily life (stepping off of a curb, going down a flight of stairs, or making a sudden change of direction).

These complaints have been called “predictable” instability, in which a particular maneuver causes feelings of instability and the patient learns to avoid the inciting movement, or “unpredictable”, in which the instability occurs in situations the patient cannot anticipate nor prevent.

What are the Treatment Options?
Treatment for anterior cruciate ligament injuries is divided into surgical and nonsurgical.  The nonsurgical choice of treatment includes strengthening and conditioning of the supportive muscles around the leg, at times using supportive braces.  These braces are not typically worn during activities of daily living, but are more commonly used for sports.  Although the philosophy regarding the use of these braces varies from doctor to doctor, it is Dr. Fox’s opinion that these serve as more of an anchor and reminder regarding the underlying problem as opposed to a true prevention of movement.

The percentage of patients who are satisfied with a nonsurgical choice vary with the level of activity of the individual patient, body types, age, and stress that the extremity is placed under.  Obviously, those with the least amount of activity and stress seem to be the most satisfied with nonsurgical care.

What are the Surgical Choices?
All the surgeries available at the present time for reconstruction of the anterior cruciate ligament utilize placing a tendon or “collagen” material in the course of the damaged ligament, fixating it into place through drill holes and holding it in place with fixation devices (either metal or absorbable).  This tendon serves as a “scaffolding” or a bridge for the body to grow in new tissue.  This new tissue slowly modifies itself through the body’s natural processes to form a type of scar tissue which seems to give adequate anterior stability in approximately 80 to 90 percent of the cases.

Is the “New Tissue” a Normal Anterior Cruciate Ligament?
Biopsies and microscopic analysis, including special high-powered electromicroscopes, show this is a type of scar tissue and not normal “ligament” tissue, but it seems to function quite well.  The body’s response to all the various types of tendons which have been used for reconstruction appears to be quite similar.  Some grow in slightly slower than others, but the end results appear equivalent.

How Long Does it Take for the Body to Perform this “Remodeling”?
The remodeling process extends over one to two years with constant change and modification of this underlying tissue responding to the stresses and strains to which it is exposed.

What Types of Tendons are Available?
Tendons commonly used for reconstruction are: 
(1) The central third of the patellar or knee cap tendon.  This is performed using a small piece of bone from the kneecap and another one from the shin bone area to help in fixation. 
(2) The hamstring tendons.  These lie behind the knee and are commonly used as multiple strands, with three to four strands of tendinous tissue.
(3) Donor tendon.  This is obtained from a tissue bank.

Is One Type of Tendon Stronger than Another?
Many different types of biomechanical testing have been performed on these various tendons.  In Dr. Fox’s opinion, they all appear to be equivalent.  Variation and interpretation of testing methods have their advocates.

Does One Tendon Appear to Have Better Results than Another?
In our own comparisons, the results appear to be similar between all three choices.  The patellar tendon appears to be slightly stiffer in its testing, but as far as the patient satisfaction, return to sports function, the choices all appear to be equivalent.  Therefore, the end results appear to be similar, and we have not found a distinct preference.

Why Does One Surgeon Prefer a Particular Tendon for Reconstruction?
It seems that preference has to do with the surgeon’s own particular experience and the comfort level of the surgeon and his or her staff in performing particular operations.  These biases are logical and seem to be representative of the practice of medicine, where each individual practitioner has his or her own personal choices.  Dr. Fox’s personal choice leans toward the hamstring tendon or the allograft.  If his patients prefer to use the patellar tendon, he is happy to refer them to another physician who uses that on a more frequent basis.

Why May a Certain Tendon Not be Used at Times?
We have encountered situations where patients with tears of the anterior cruciate Ligament have also sustained tears to the patellar tendon and, obviously, that tendon would not be able to be used for reconstruction.  In patients with chronic problems in the front of their knee, such as chronic tendinitis or pain and discomfort in the front of the knee, a surgical procedure in that area may increase these difficulties.

We have also encountered patients who have sustained tears of their hamstring tendons or damage on the inner side of the knee or posterior aspect of the knee which did not allow the use of the hamstring tendons.  If the primary choice has been damaged, alternatives may have to be discussed.

What Particular Problems Have Been Seen with the Different Types of Grafts?
Problems which have been encountered with use of the patellar tendon are quite logical.  In particular, numbness of the front of the knee, tenderness and discomfort of the scars across of the front of the knee, residual aching and discomfort where the tendon has been harvested, chronic tendinitis, and increasing pain and discomfort over the kneecap (called “chondromalacia” of the patella).  Very rarely, separation of the remaining patellar tendon or fractures of the patella have occurred.

Problems of using the hamstring tendons have been numbness and discomfort along the inner side of the shin bone area (due to damage to a small nerve called the sartorial branch of the saphenous nerve which runs through the hamstring muscles).  Also, residual aching over the hamstring muscles behind the thigh area and scarring behind the thigh.

What are Particular Risks and Problems of Using a Donor Tendon?
The greatest concern that we have is the possible transmission of various types of viral diseases.  Although the tendons are obtained from certified tissue banks which use acceptable screening and sterilization methods of the tissue, there is a risk that infected tissue may somehow not be picked up through their screening processes and could be utilized.  We do not know the exact incidence of this risk, but various statisticians have reported a chance of approximately 1 in 1,000,000.  These exact statistics remain unknown.  To the best of our knowledge, in recent years with the screening, testing, and sterilization methods used, no one has been exposed to these viruses, but we remain concerned.

Are the Concerns About Virus Communication the Same as in the General Population?
Yes.  We remain very concerned in the health profession regarding the communication of various viral diseases. Testing is not standard in the medical community for surgical procedures or medical care; we expect the patients who do undergo reconstruction with donor tendons to have testing performed prior to surgery and then again at approximately four to six months after the surgery for additional laboratory confirmation of their status.

What Happens Before My Surgery?
It is routine that you will be seen in the office one to seven days prior to the surgery.  At that time, last minute questions can be answered and you will be fitted with your postoperative brace.  You will be provided with a preoperative kit including a depilatory cream to remove hair in the surgical area, cleansing sponges, and dressings.  If you do not have your own crutches, these will be dispensed.

We would be happy to refer you to the physical therapy group in our building for your preoperative evaluation.  However, if there are therapists at a more convenient location to you, this can be arranged ahead of time for appropriate crutch instruction and an initial postoperative exercise program.

At times, between office visits patients do develop various types illness such as upper respiratory infections, colds, flu symptoms, or gastrointestinal problems.  If this does occur, please remember this is elective surgery and notify us so the surgery can be postponed until you have recovered.

If there is any history of medical problems, if you have been under a physician’s care previously, you should be evaluated prior to your surgical procedure.

If you have a history of allergies to particular anesthetic materials or antibiotics, please let us know so that this can be addressed.

What Should I Do the Night Before Surgery?
You will be instructed on how to cleanse the skin ahead of time and follow the directions on the depilatory cream (PLEASE TEST THIS PRIOR TO APPLYING TO THE KNEE JOINT AREA TO MAKE SURE YOU DO NOT HAVE A REACTION TO THE CREAM).

Do not eat or drink anything after 12:00 midnight.  If you are taking required medication, please discuss the use of this with the anesthesiologist.

How is the Surgical Procedure Performed?
The surgery is performed on an outpatient basis.  It involves an anesthesia, either a regional anesthesia called epidural where the lower extremities are numbed, or a general anesthesia.  This anesthesia is administered by a Board Certified anesthesiologist.  It is important that you discuss any questions you have about the anesthesia.  Please feel free to call the anesthesia department at (818) 901-6690, extension 4111.

The surgery usually lasts approximately 1 to 1½ hours.  It is performed utilizing the arthroscope to visualize the interior of the joint, but also incisions are used to harvest the tendons (if your own tendon is being used) or for drilling the appropriate bone tunnels and fixation within these tunnels.  A qualified assistant is needed in surgery in order to help position the equipment, camera and instruments.

After the surgery is completed, you will be transferred to the recovery area and the ice pack you will bring to the surgery center will be applied to your knee.  You will be kept there until you are fully awake, able to ambulate and have urinated.  If you are experiencing discomfort, medication will be provided.

After you are cleared by the recovery room nurses and the anesthesiologist, you will be able to be discharged home.

Will I be Using a Brace and Crutches?
Patients are fitted with a knee brace which limits range of motion and crutches for use postoperatively.  Weight bearing is allowed at the patient’s comfort.  When not ambulating, the brace should be removed and an early range of motion exercise program instituted immediately.

As stated above, weight bearing is allowed immediately at comfort, but crutches should be used until the patient can ambulate safely with good muscular control.

The brace and crutches should be used when in an unsafe or unfamiliar environment (i.e., where people are pushing or shoving) where there is a high risk of re-injury.  The average length of time for using the brace and crutches is approximately one to three weeks, depending on comfort and control.

What are My Activities at Home?
You may be active within your comfort.  We suggest for the first 24 hours that you be careful with your diet, not eating hot, spicy and difficult to digest foods.  At times the medication which you are taking - antibiotics, pain pills - can cause some stomach distress.  You should be aware of this.

You may be up and about depending upon your comfort and feelings of security.  At mentioned above, you may weight bear at your comfort, using the crutches for external support.  When you are not walking, please remove your brace and begin your exercise program and range of motion.  You may perform these at your comfort.

When Can I Leave My Home?
When you feel that you can safely ambulate and are not experiencing any dizziness, you may leave your home.  Again, we would suggest going in slow increments to make sure that you are comfortable and not experiencing any side effects.

How Do I Use My Ice Pack?
There are advocates for many different cold therapy regimens.  Some physicians and therapists have recommended cold application for brief periods of time, approximately 20 minutes, then approximately 20 minutes without ice.  Others use it on a continuous basis.  From experience, this appears to be an individual decision, therefore we would suggest trying different patterns and see which one works the best for you.  Each person seems to respond differently, so we encourage you to use your judgment and comfort as a guide.

What About Medication?
You will be given a prescription prior to your surgery for  an antibiotic, usually prescribed as a derivative of penicillin, which is to be used for a total of six doses.  This is to be used prophylactically and longer term use should be discussed with your physician.  You will also be prescribed pain medication and a sleeping tablet.  These medications can make you groggy, therefore we suggest that you should as soon as possible try over-the-counter medication which you have tolerated in the past without difficulty, and to reserve these other medications for those situations which are unresponsive to the over-the-counter medications.

When I Took My Brace Off, I Noticed There was Some Oozing on My Dressings.  Is This Normal?
Very commonly, there is some oozing from the surgical incisions.  This should not be frightening, but if it worsens, our office should be contacted immediately.

If I Have Questions, Concerns, or I Do Not Seem to be Recovering, What Should I Do?
Contact our office immediately at (818) 444-5100.  There is always a doctor on call.  This may not be Dr. Fox, but the doctor on call can be paged by the answering service.  There have been rare occurrences when we have had problems with our phone lines (this has only happened five or six times in the history of the Orthopedic Institute over the last 20 years).  If this should occur, go to your local hospital emergency room or, if you do feel this is a life or limb threatening emergency, call the emergency 911 system.

How is the Graft Held in Place?
The graft is held in place with small metal devices (screws, staples and other fixation devices) or, at times, absorbable apparatus.  There have been occasions when these have had to be removed because of sensitivity or discomfort and this may involve a secondary operation.

What are Some of the Standard Risks of the Surgical Procedure?
Standard risks include:
(1) Reaction to the anesthesia (please discuss this with your anesthesiologist).
(2) Scarring and limitation of movement which may require additional surgical procedures and which may be of a permanent nature.  Although this is not common, it can occur.

(3) General risks of surgical procedures, such as infection, blood clots, delay and/or failure of healing, and also the risk that the surgical procedure may not be effective and the graft may progressively fray and deteriorate, causing recurrent instability.  There is also the risk of progressive deterioration of the joint, with or without surgery.

I Have Heard that Some Special Devices Such as Cooling Machines or Range of Motion Apparatus are Needed.  Is This True?
In normal anterior cruciate ligament reconstruction, this equipment has not been found to be necessary.  When comparing results with and without special apparatus such as range of motion machines or special cooling devices, we have not found a significant improvement nor benefit to the patient.  Therefore, it seems if patients work on their range of motion and use the cold packs as recommended, the special equipment can be avoided.  The reasons for not using them are not purely financial; we feel that they can encumber the patient, delay the aspects of beginning weight bearing and ambulation, and delay the active use of control and exercise.

I am Traveling to See Dr. Fox From Out of Town.  Do You Have Any Suggestions?
A number of our patients do travel significant distances for their surgical procedure.  Obviously, an appropriate caregiver should be with you, since, as noted above, these surgeries are outpatient procedures. 

We can suggest various local hotels and refer you to research further costs.

We would recommend a full-service hotel with room service, as you will be in your hotel room for several days following the surgery and will not be comfortable in a public restaurant environment.  We also recommend that you check with the hotel to make sure a freezer is available in your room to maintain the cold packs.  Transportation in Los Angeles can be a problem and we suggest you make the necessary arrangements, either with a rental car or a limousine service.  We can refer you to various limousine companies.

When Do I Begin My Rehabilitation Program?
You begin your rehabilitation program even before surgery, starting your exercise, regaining your range of motion, working on your strength and conditioning, and general aspects of health including weight reduction, discontinuation of negative factors such as smoking.  It is extremely important to have good health and weight habits, not only at the present time but also in the future.

Patients begin a guided therapy program at approximately one week after surgery, emphasizing return of range of motion, strengthening and conditioning, but it is important for the patients to work with their therapist to develop a good independent program that can be continued.  Most therapists over a three to six week period of time have been able to establish this with the patient.  Rehabilitation and exercises require personal commitment.  The therapist can give suggestions and professional advice, but it is your responsibility.

When Can I Return to Work?
This is dependent upon what is involved in your work situation.  If you have a relatively light or sedentary type work, most patients seem to be able to return to work in approximately five to seven days.  However, with more strenuous work involving being on your feet, twisting and turning, lifting and carrying objects, etc. can be delayed for four to six months, depending on the type of activity.  In fact, some people have not been able to return to highly stressful work and have to make adjustments and changes in job descriptions.


 


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