|
ACL Reconstruction (Anterior Cruciate Ligament)
When the ACL tears, in most cases, it explodes. That is why many people feel a "snap" or a "pop" at the moment of
injury. As such, the ligament is not repairable and must be "Reconstructed". In brief, the doctor must make a "New"
ligament using some other tissue or "Graft". There are three (3) common choices of tissue which can be used as a Graft
to reconstruct your ACL. Each choice has it's pros and cons. Below is a summary of the issues involved in
Graft selection.
Where?
Your surgery will be performed in an outpatient setting. Dr. Kimball performs this procedure at UVRMC, CUSC and
Timpanogos Hospitals. The choice of facility is determined by your schedule, Dr. Kimball's schedule and the provider
options on your health insurance policy.
How?
Anesthesia:
Your surgery will most likely be performed under general anesthesia. Under some circumstances a spinal anesthetic may
be used. You will be able to discuss these options with the anesthesiologist when you come to the outpatient surgical
facility. A femoral nerve block will be offered as well. This in an injection of a novacaine-like medication near the
femoral nerve in your upper thigh. It has a numbing affect and will diminish the post operative pain for anywhere from
6 to 24 hours.
Night before surgery:
It is imperative that you have nothing to eat or drink for at least 6 hours prior to surgery. If you are an early
morning surgery, then you should have nothing to eat or drink after midnight.
Your leg will be scrubbed with antiseptic soap at the time of surgery. It is wise to do the same at home the night
before surgery. If you have a pimple or other site of infection either on the injured leg or any other part of your
body, Dr. Kimball will likely delay your surgery until that infection is resolved. When in doubt, ask the doctor.
Infection is a terrible complication following surgery. It is usually inappropriate to do surgery in the presence of
infection.
Day of Surgery:
You will be notified by the surgical center as to the time you are to arrive. Laboratory or other tests may be done
upon your arrival. You will be notified by the surgical center if special tests need be done prior to your arrival.
The Proceedure itself:
You will be taken to the operating room. Appropriate anesthesia will be administered. The leg will be prepped with
antiseptic solution then sterile drapped.
Examination Under Anesthesia:
Dr. Kimball will perform stress tests on you knee to verify and document the degree of instability. He will check for
instability of the ACL, the MCL, the LCL and the PCL.
Diagnostic Arthroscopy:
Small incisions (approximately 4 mm) are made in the front of the knee joint. An arthroscope is introduced into the
joint. The joint is infused with a physiologic solution. The joint and all structures are examined visually employing
a video system. The arthroscope is a small tube with internal fiberoptic light and is attached to a video camera which
directs the inside of your knee joint onto a video screen. Dr. Kimball routinely takes a series of still photographs of
the findings in your knee such that he can demonstrate to you what he found and what he did. He can usually provide you
with your own copy of photographs and will do so at your first post operative office visit.
Dr. Kimball looks the joint surfaces, the tracking of the patella, the medial and lateral meniscus and the anterior
(ACL) and posterior (PCL) cruciate ligaments.
Upon completion of the diagnostic portion of the procedure, Dr.Kimball is prepared to proceed with repair and or
reconstruction of the damaged structures.
Cartilage Repair
The treatment of cartilage (joint surface) injuries is frequently an important part of the treatment of knee injuries.
Often serious knee injuries (torn ACL) are associated with injuries to the joint surface. The management of these injuries
require that the surgeon become a BIOSURGEON. This involves the application of treatments and surgical techniques that promote
healing or regeneration of the injured joint surface.
There are many treatment options. It is the surgeon who decides which technique to apply to a given joint surface injury.
- Lavage and Debridement
This is a very limited process consisting of cleaning, smoothing or shaving an injured or damaged joint surface.
Pro: Removes debris, spurs and rough spots on the joint surface which can, to a limited degree, reduce some of the mechanical
symptoms of "catching", "locking" or "giving out".
Con: This procedure does not promote "healing" or "regeneration" of the surface injury. If improvement occurs it is usually short lived
and does not significantly alter the course of the underlying disease.
Applications: May have limited use in treating either a minimal joint surface injury or in temporarily reducing mechanical
symptoms in a severely injured joint surface.
- Drilling and/or Abrasion Arthroplasty
This technique involves araiding the exposed bone in order to stimulate healing and regeneration of tissue. This technique
has largely been replaced by "Microfracture" technique described below.
- Microfracture (Mesenchymal Stem Cell Stimulation)
This procedure is often applied to relatively small, localized joint surface lesions. This is an arthroscopic procedure and consists of
scraping or trimming away the loose, damaged cartilage, lightly scraping the surface from the exposed bone, then creating holes in the
exposed bone approximately 2-3 mm. apart. This creates a rough surface for the ensuing blood clot with undifferentiated mesenchymal cells
(stem cells) from the marrow to adhere. In other words, a blood clot derived from the bone marrow, fills the defect in the articular surface.
If all goes well, this clot will become a "fibrocartilage" patch which fills the defect in the joint surface. Most patients are significantly
improved by this procedure.
Pro: Relatively easy to perform. Response and recovery is quite predictable
Con: It is important to protect the healing tissue. This means crutches with only "toe-touch" weight bearing for 6 weeks. It is also
important to do passive range of motion several hours per day or apply 1500 unloaded cycles of range of motion per day.
Applications: Used to treat relatively small full thickness cartilage injuries in the under 50 age group.
- Osteochondral Grafts
Some lesions are too large to respond favorably to microfracture procedure. In these situations the injured surface may be "replaced" by
transporting cartilage "plugs" from one site (less important) in the knee to another (the site of the painful lesion). These "plugs" or
in some cases larger pieces of bone and cartilage can be transported from the same knee (your knee). These are called Autografts. Or they
may be obtained from an organ donor. These grafts are called Allografts.
When a small graft or grafts will suffice, they are obtained from a less important part of the injured knee. When a very large defect must
be treated, the graft must come from a "donor". Allografts are obtained from Tissue Banks.
- Autografts:
Pro: Can effectively heal relatively large full thickness cartilage lesions. Not associated with risk of rejection from donor material.
Not exposed to risk of disease transmission from organ donor.
Con: Size of treatable lesion is limited by need to harvest donor material from another part of the same knee. Thus amount of
transportable graft material is limited.
Application: Treatment of relatively large full thickness cartilage lesions.
- Allografts:
Pro: Can be used to treat large lesions. No limitations on size or amount of graft material.
Con: Requires implanting biologic material from organ donor thus there is risk of disease
transmission from donor, risk of infection from tissue bank processing and risk of rejection from immunologic reaction.
Application: Treatment of very large full thickness cartilage and bone lesions.
Autologous Chondrocyte Implantation (ACI)
This is a very special type of Autograft. Cartilage cells are harvested ( via arthroscope), sent to a special lab where the
cells are cultured to increase their numbers, then the cells are implanted using a very special technique. This enables one
to "regrow" cartilage tissue and fill the defect.
Meniscectomy
This is one of the more minor arthroscopic knee surgeries. Your procedure is designed to remove the torn part of your
meniscus. The goal is, through 3 small puncture wounds, to enter the knee with an arthroscope, visualize what is wrong
employing a television monitor then, using very small instruments, remove the damaged part of the meniscus. The
procedure usually takes less than 30 minutes.
I have performed this operation thousands of times. You can expect to go home with a slight limp, be sore then next day
and then gradually improve. I expect that you will be walking near normally within one week and back to full activity
within one month.
Most patients do not require formal physical therapy following this procedure. Most do not require crutches.
The risks associated with this procedure are similar to any operation. We worry about infection, anesthetic
complications, medication reactions and blood clots following surgery.
For more information see section dealing with potential complications following surgery.
Meniscal Repair
In some cases it is more appropriate to repair the torn meniscus rather than remove the torn part. This decision is
determined by the nature, location and type of tear that is encountered. Some areas of the meniscus have adequate blood
supply and have the ability to heal if repaired. Other areas are without sufficient blood supply and thus do not have
the ability to heal.
The "red zone" is the term we use to describe the areas that have potential for healing. The "white zone" does not have
the ability to heal.
When I repair your meniscus I will either suture (sew) it back together or repair it using a special biodegradable
"tack" to hold it together while the healing occurs. Healing takes time and I will usually require that you use
crutches 3 to 4 weeks following a meniscus repair and limit your return to vigorous activities for 3 to 4 months. Even
if we do everything right, you meniscus may not heal and it may be necessary to come back at a later date and re-scope
the knee and remove the part that did not heal.
I am more likely to repair a torn meniscus in a younger person as the impact of saving the meniscus will have greater
import.
Patellar realignment surgery
Osteochondritis Dessicans
|
