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EXPERT ADVICE: Frequently Asked Questions
ACL injury and repair
Q: What is ACL shrinkage? A friend told me a little bit about it, but I would like to know more.
Answered by David Golden M.D. on November 20, 2002
A: With a specialized instrument, the fibers of the ACL are changed and attenuated, thereby shrinking the ACL. Theoretically, it may correct laxity but has not been well established in the literature. Currently, ACL deficiency causing symptoms is treated with reconstruction, not shrinkage.

 
Q: How permanent is a chronic complete ACL tear? Will it ever heal completely or is this a permanent disability?
Answered by Ken Alleyne M.D. on November 06, 2001
A: If the tear is complete it will not heal. The issue really is how much instability you are having in your knee. The presence of a tear is not a reason for surgical intervention. The presence of a tear and instability in the knee would require more intervention either via physical therapy or surgery.
 
Q: Ten weeks ago, I had an arthroscopy. The surgeon found that I had snapped my ACL and removed it. This injury happened 10 years ago playing rugby. With 10 years wear of the knee and now no ACL am I more prone to arthritis in later life?
Answered by Ken Alleyne M.D. on November 06, 2001
A: Your being prone to arthritis will surround instability in your knee. If your knee is unstable and “gives way” you will run the risk of causing more damage in the knee, which could lead to arthritis. If the knee is stable, which is quite possible with an ACL injury, then your risk is not increased.
 
Q: Is there any medical evidence to suggest that certain specific types of exercise routines, procedures or techniques can be used to strengthen the knee to help it better resist ACL type injuries?

Do squats and lunges with weight help build knee strength that may reduce the chance of an ACL tear or are they bad for your knees?
Answered by Ken Alleyne M.D. on November 06, 2001

A: There is significant evidence that plyometric exercises and overall strengthening of the muscles about the knee can have a protective function.

Squats and lunges done appropriately can be helpful to strengthen the muscles about the knee, thus imparting greater stability. There are other exercises that can be done to strengthen the quadriceps that put you at less risk for other issues that come with squats and lunges but those exercises are fine if done correctly.

 
Q: About 8 weeks ago I had and ACL reconstruction performed on my left knee by having a patella-tendon autograph. Is it possible for the 1/3 of tendon they took out to grow back? If not, will I have any pain about ten years later around my patella tendon? I am 15-years-old.
Answered by Ken Alleyne M.D. on November 06, 2001
A: That portion of the tendon will fill in with tissue that will partly look like what was removed and partly be a form of scar tissue. The history of this procedure has been that removing that portion of the tendon to do the autograft has not been problematic and more than likely should not be of a significant concern.
 
Q: About 30 years ago I completely tore my ACL. About 15 years ago I completely tore the ACL in my other knee. The oldest injury is real loose, and I wear DonJoy braces on both knees. Sometimes it feels like a knife is stuck in my knees; the pain is quick and very sharp. Have things advanced for reconstruction of old injuries?
Answered by Ken Alleyne M.D. on November 06, 2001
A: The issue is instability in the knee not so much the fact that the ACL is gone or that there is pain. If you knee is stable then an arthroscopy may be in order to delineate the source of pain…torn cartilage…scar tissue etc. Reconstructing of a 15 year old injury is possible but this largely depends on the overall state of the knee.
 
Q: I tore my ACL 12 years ago but never had time to do the surgery. Now, I am thinking of doing the surgery, although my knee does not bother me too much. Is there any correlation between the age of the injury and the success of the operation?
Answered by Ken Alleyne M.D. on November 06, 2001
A: The earlier any surgery is done usually is a better outcome. A late reconstruction is not that uncommon. If your knee is not bothering you then why have it reconstructed? There is a higher correlation between the overall status of the knee and the motivation of the patient then the age of the injury. This assumes there is no other damage inside the knee.
 
Q: How long will an ACL reconstruction last before it deteriorates, and what is the prognosis for old age (65-80)? I have moderated my lifestyle and exercised prudently with low impact workouts and good nutrition.
Answered by Jack Farr M.D. on October 26, 2001
A: If the reconstructed graft is in the proper position, has reestablished near-normal laxity and ingrown with your own tissue, it should potentially last a lifetime. Studies vary on the incidence of degenerative joint changes and progression after ACL reconstruction, but your prudent workout program will help optimize longevity.
 
Q: Six days ago I had ACL reconstructive surgery with the graft coming from my own patellar tendon. When lying down there is little pain at all and I can bend my knee without much pain. However, when I stand upright I now get excruciating pain in my knee and slightly below. Is this normal? Is it just my graft area in the process of healing?
Answered by Jack Farr M.D. on October 26, 2001
A: Consult your surgeon, as only they know your knee. In general, if everything is going well and the isolated problem is pain upon standing upright, it is not uncommon for the blood of the procedure to have migrated and irritated soft tissues. When you stand, the veins fill with blood and expand, causing usually a burning pain, which then slowly abates. Moving very slowly to the standing position seems too easy a solution, but it often helps if this scenario is the problem.
 
Q: I had ACL surgery about 13 months ago. Recently my knee has been hurting after I sit for a while or do too much exercising or walking. Is this normal?
Answered by Jack Farr M.D. on October 26, 2001
A: Your surgeon would want to know how you are doing. Only they can diagnose your problem. Pain which occurs after sitting is often patellofemoral in nature and may be related to incomplete rehabilitation of the quadriceps, so consult your surgeon to see if this is the case.
 
Q: I am a fairly active 46- year-old woman. I have a high-grade ACL tear. My surgeon suggests surgery is not the way to go due to age, and that it is routinely done on people under 30. Do many adult women have successful ACL surgery at my age?
Answered by Jack Farr M.D. on October 26, 2001
A: The surgery can be successful at an even older age. The question is do you need surgery for your lifestyle. Your surgeon's conservative approach is common for most surgeons. If you feel you need surgery then discuss your sporting desires in detail. In questionable cases, an option is to use an ACL brace and compare stability in and out of the brace.
 
Q: I recently had an ACL reconstruction and all appears to be going well. My only concern is that I still feel movement between my tibia and femur, and I experience "clicking" noises between bones. Have I stretched the graft or is this a normal symptom to experience? Does the graft over time rectify this movement by becoming stronger?
Answered by Jack Farr M.D. on October 26, 2001
A: Clicking and other noises are common and do not mean anything is wrong. Until the muscles are fully strong, there may be a sensation of movement even with a reconstructed ACL. Your doctor can tell by exam if the graft is loose.
 
Q: My son had reconstructive ACL surgery on his right knee after a football injury using the patella tendon. He has been dedicated to rehab and has resumed his regular activities, yet his knee still swells after any strenuous activity, namely football games. His doctor is pleased with the outcome of the surgery and sees no postoperative problems. Is the swelling common with ACL repairs? Will it subside as his knee adjusts to the increased activity?
Answered by Jack Farr M.D. on October 26, 2001
A: Swelling early on is not uncommon. In a fully rehabilitated knee several months after surgery, swelling may suggest meniscal or articular cartilage problems. Your surgeon will know if that is the case.
 
Q: I have had two ACL reconstructions, the most recent for a re-rupture. The second surgery has "felt" good, but I have continued instability and MRI shows quite a vertically placed graft. Do I have any options for the instability? Is my only choice bracing for the rest of my life in all the sports I participate in?
Answered by Jack Farr M.D. on October 26, 2001
A: The first step is to determine if the present graft is functioning properly. That is, are there other problems causing your instability sensations. If the graft is nonfunctional then your surgeon needs to decide if re-revision ACL surgery is more advisable than bracing.
 
Q: I am 30 years old and just had surgery because of two partial tears of my ACL. What can be expected in the long run?
Answered by Jack Farr M.D. on October 26, 2001
A: Surgery is a generic term and could include arthroscopy alone or in conjunction with ACL Reconstruction. Without ACL reconstruction, the probability of instability is highly dependent on your activity level, the status of the other ligaments and the extent of rehabilitation. Long-term problems with degenerative arthritis are highly dependent on the status of the meniscal and articular cartilage, your alignment, weight and activity. These are great points to discuss with your surgeon.
 
Q: I had my ACL repaired and unfortunately, I just re-ruptured the same knee. Should I have the surgery again? Will it happen again?
Answered by David Golden M.D.
A: There are different reasons why your graft may have failed. It depends on the length of time following the surgery that the re-rupture occurred. If it occurred soon after surgery, there may have been a failure of the fixation of the graft. If it occurred later, a traumatic tear may have ruptured it, similar to the cause of the initial tear. Whether you should have surgery again is answered by the same set of questions that you initially considered. It depends on your activity level and/or symptoms of instability. The indications for the surgery do not change because it is a revision.
 
Q: I tore my ACL, but do not want to have reconstructive surgery. Are there any changes that I need to make in my lifestyle or my exercise routine?
Answered by David Golden M.D.
A: Yes, lifestyle changes need to be made. The decision to have surgery depends on the demands you place on your knee. Often, it is correlated with age and activity level. If you elect not to have your ACL repaired, you will need to avoid high-impact or cutting motions, as well as contact sports. Straight away running and closed-chain exercises are excellent for conditioning and strengthening. Be sure to ask your doctor about appropriate strengthening exercises.
 
Q: I recently had ACL reconstruction done. I am doing extremely well in my physical therapy program and would like to return to competitive sports. Do you recommend that I wear a brace? Do you have any other recommendations?
Answered by David Golden M.D.
A: Brace recommendations vary among surgeons. There is a recent trend towards not bracing upon return to sport. However, some surgeons feel the extra level of protection is warranted. The fixation of the ACL graft and the conditioning and strengthening of the operative leg compared to the non-operative leg may be as important as the concept of bracing. Most surgeons have a fairly strict rehabilitation protocol that patients must follow before being allowed to return to sports. Ask your doctor about the safety in returning to sport at this time.
 
Q: An MRI revealed that I have a complete ACL tear. What are my options for repair?
Answered by David Golden M.D.
A: There are operative and non-operative options. Your age, lifestyle, and activity level will help you and your doctor decide if surgical reconstruction is a viable option. Non-surgical treatment entails conditioning and strengthening of the injured knee. Activities must be curtailed to meet the limits of an ACL deficient knee. Operative treatments vary as well. There is a choice of grafts to reconstruct the ACL. The patellar tendon, the hamstring tendon, or allograft (from another person) are viable options. Be sure to ask your doctor about the risks and benefits of one over another.
 
Q: What is the difference between autograft and allograft reconstruction? Is one better than the other?
Answered by David Golden M.D.
A: Autograft means that the graft comes from your own body. Allograft means that the graft comes from another person (cadaver). There are advantages and disadvantages to both. An autograft may heal faster because it is from your own body, while an allograft may be recognized as a foreign substance and take longer to heal. The donors for allograft are well-screened, and the graft is treated to kill viruses but there is a very small chance of viral infection transmission with these grafts.
 
Q: I recently had an ACL reconstruction. How long does a typical recovery take? Can you please give me some tips to help my recovery go faster?
Answered by David Golden M.D.
A: ACL recovery cannot go faster. There is a definite time during which the graft heals to the host bone and the fibers change in constitution, sometimes becoming vascularized (gaining blood supply). Accelerating the rehabilitation may injure the repair during the healing process. Typical recovery, depending on the type of graft and the type of fixation, spans seven to ten months. There are steps you can take to advance the strength training, but cutting and impact are not allowed until the last phase of rehabilitation. Follow the instructions of your surgeon. Do not push too hard and risk stretching the graft or injuring the knee further.
 
Q: I partially tore my ACL and I have not yet had surgery. My knee doesn’t bother me much, and I wear a brace when participating in certain sports. Is it worth having the knee cleaned up and repaired?
Answered by David Golden M.D.
A: Surgery for the knee treats pain, instability, or the risk of future degeneration from injury. If you function well and have no pain, perhaps continuing with your current status is a good option. If instability becomes a problem, reconstruction can take place at any time. Having the knee “cleaned up,” I assume, refers to arthroscopy. The same applies to that surgery, too. If you are having problems, are at risk for future injury, or having pain a diagnostic and partially therapeutic arthroscopy may help. Be sure to talk to your doctor about the indications for surgery and appropriate rehabilitation steps to take if you elect not to reconstruct the ACL.
 
Q: A lot of my friends have ruptured their ACL. Is there anything I can do to prevent this from happening to me?
Answered by David Golden M.D.
A: No. There are no specific strengthening exercises that are proven to prevent ACL injury. Appropriate stretching may aid in muscular flexibility and contribute to better dynamic stabilization of the knee.
 
Q: I recently ruptured my ACL. My doctor has discussed harvesting tendons to repair this injury: What is the difference between a patella tendon and a hamstring tendon graft?
Answered by David Golden M.D.
A: The patellar tendon is taken from the middle third of the tendon that attaches the kneecap to the leg bone (tibia). Small pieces of bone are taken with it to allow attachment to its new site. The hamstring graft is harvested from the tendons in the back of the thigh. There are advocates of both sources of grafting. Good surgical technique and appropriate postoperative patient compliance is the key to a successful outcome of ACL reconstruction. There may be minor differences in postoperative rehabilitation protocols, and some surgeons think there may be a difference in postoperative knee pain. Ask your doctor about the differences in grafts and discuss which may be best for your reconstruction.
 
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