Arthroscopic ACL Reconstruction

Now that you have decided to undergo Anterior Cruciate Ligament (ACL) reconstruction surgery, here are some important things for you to know regarding the pre and post-operative preparation and care of the knee in order to ensure a smooth recovery.

PRE-OPERATIVE PREPARATION

Explanation of Procedures

The surgeon will explain the benefits, the risks and complications of the procedure that you are to undergo.  Do not hesitate to ask the surgeon to explain any part of the procedure.  Do note, however, that the results vary from patient to patient.

Hospital Documentation

The Practice will assist you in the preparation, documentation, insurance and admission procedures to the Hospital. 

The Admission Office for Day Surgery at the Mount Elizabeth Hospital is at Level 3 of the main hospital building.  The Day Surgery Ward, to which you will be admitted, is at the same level.  There are individual safes available for patient use at the Day Surgery Ward.  It is advisable not to bring any valuables when you come for surgery.

For in-patient admission, the Admission Office is at Level 2.

Prior to surgery, you will be required to sign an informed Consent Form, which states the nature of the surgery and provides consent for additional procedures, which your surgeon may deem warranted during the course of surgery, should complications arise.

You will be required to come to the clinic at 9AM on the day of surgery.

EMERGENCY CONTACT

If you have any doubts, concerns or need advice, please contact our office.  After office hours, please contact the answering service and they will get you in touch with Dr Raj.

24-HOUR ANSWERING SERVICE: +65 6333 5550

Outcome of ACL Surgery

Success rate of ACL surgery is around 85-90%. Repeat surgery may become necessary under certain circumstances. Hamstring grafts are widely used in this practice and this may slightly weaken your hamstring following surgery.

Meniscal injury predisposes a patient to wear and tear and arthritis in the long-term.  An Allograft tissue from a tissue bank is also used fro ACL reconstruction under certain circumstances.  The risks of allograft tissue includes infection, disease transmission, incorporation issues and weakness of graft tissue.

Not all pathological findings or defects in the joint are amenable to surgical correction.  This is particularly true if you have any articular cartilage defect or osteoarthritic changes, in which case your symptoms can be improved to a certain degree but it may not be possible to alleviate the symptoms.  You may also need to modify your activities in line wiht the severity of the symptoms.

Return to Activity

It is generally advisable to delay return to sports until the primary pathology has been treated or resolved completely. Premature return to strenuous activity may precipitate effusion or irritation of the joints.  Do note that returning to activiy may take two to four months.

However, do not wait until your injury is healed to get back into shape. To aid speedier return to activity, follow the RICE formula: Rest, Ice, Compression and Elevation, along with a limitation of activities. Do stay fit while injured, and keep a positive, upbeat attitude.

PRE-OP DOS & DON’TS

DO avoid alcohol the day before surgery

DO stop smoking for a few days before and after surgery

DO abstain from food and water from midnight before the day of surgery

DO wear lose clothing in order to accommodate post-operative dressings and braces which may be required following surgery

DO inform your doctor of any pre-existing ailments, diseases and drug allergy

DO let your doctor know all medications that you are currently taking, such as aspirin, vitamins or herbal supplements, as they may affect your surgery. If you are taking aspirin or anti-coagulants, you may have to stop the medication 14 days before surgery

DO ask your doctor when to take any of your usual medications (e.g. for diabetes, hypertension or heart problems) and how much to take before your surgery

DO notify your surgeon immediately if you develop a cold, fever, sore throat or infection prior to surgery

DO take pre-medication on the day of surgery, which will be prescribed, to reduce the incidence of post-operative pain and complications

DO NOT wear any jewelry and make-up and remove all body piercings and nail polish

DO NOT drive to the hospital on the day of surgery

You may consume small amounts of clear liquids up to six hours before you arrive for surgery. This will reduce your chances of nausea and vomiting after surgery.

OPERATION

Arthroscopic surgery is carried out under general anesthesia.

We perform most of these surgeries at Mt. Elizabeth Hospital, which has the state of the art voice activated computer controlled minimally invasive surgery suite.

Latest technology is used where possible to expedite surgery and minimize complication and recovery time.

POST-OPERATIVE CARE

Immediately after Surgery

You will have a bulky dressing around the operated joint to prevent the accumulation of blood in the joint. A Cryotherapy (cold device) pad will be attached to your operated joint.

PCA or patient controlled analgesic pump will deliver pain relieving medication intravenously. Your leg will be elevated on pillows to reduce swelling.

You will be discharged from hospital after a day and once you are able to ambulate with crutches..

You will have to arrange for someone to drive you home, and you will require the use of crutches for 2 weeks.

Recovery Period

Rehabilitation and recovery periods vary from patient to patient. Post-operative rehabilitation is an essential part of the treatment and should be followed strictly. Your specific rehabilitation would be prescribed following surgery. 

Post Surgery Physical Therapy

This is very important following surgery and a close working relationship between patient, therapist, and doctor is vital. Generally 12-15 sessions of therapy would be required.

Use of crutches for 2 weeks and rest at home for 2 weeks greatly expedites the recovery process.

Pre-op consultation with a therapist would be arranged by the practice to improve the outcome and success rate.

A functional brace will be recommended following surgery.

Cryotherapy

A cryocuff cold therapy pad will be in place circulating cold water around the operated joint. Use the machine for two hours, rest for an hour, and repeat. It is important to turn the machine off before you sleep.

You will be instructed thoroughly on the use of this machine, and further information regarding its operation is available on our website (www.sportsmedicine.com.sg).

Complete the course of antibiotics that has been prescribed according to the instructions. Anti-inflammatory medication (Arcoxia) and painkillers (Tramium or Toradol) should be taken to reduce pain especially in the first 48 hours. Subsequently these tablets can be taken as and when required.

Dosage Instructions:

Ciprobay 250mg – 1 tab 2x a day after food (morning & evening)

Arcoxia 120mg – 1 tab once a day after food (morning)

Tramium 100mg – 1 tab at night after food (morning & evening)

Toradol 10mg – 1 tab 2x a day after food (morning & evening)

Common side effects of these medications include:

Allergic reaction, rash, stomach upset, nausea, vomiting, drowsiness.

To prevent circulatory problems and deep vein thrombosis in the limbs, it is advisable to keep the operated limb elevated as much as possible in the first few days following surgery.

Showering/Getting Around

Use cling film to wrap around the operated limb and dressing when you take a shower so as to avoid getting the dressing wet for the first few days till the wounds dry.

Use the crutches as an aid for ambulation. Do not put more weight on the injured leg than recommended.

Do avoid travelling within the first two weeks of surgery.

Knee Exercises

Post-operative swelling significantly reduces the return of rapid function to the operated limb. To reduce swelling of the limbs you should carry out certain exercises, which has been instructed to you.

Exercises for the lower limb to decrease post-operative swelling

Foot pumping exercise - that is moving your foot up and down, 10 times every hour. This will encourage return of venous blood and fluids back to the circulation. The incidence of deep vein thrombosis or blood clot in the leg will also be minimized.

Straight leg exercises - that is lifting your leg off the bed, 4-5 times every hour. This will also prevent wasting and stimulate the leg muscles.

Quad sets - which is gently pushing the knee into a straight leg position, allowing the back of the knee to touch the surface your leg is resting on. This will prevent a flexed knee position, which may compromise your walking ability.

Heel slides – which is to gently pull your heel towards you and allow for knee flexion to occur. This can be done while sitting or lying down. Do this 10-12 times every hour.

Ambulation or movement is generally encouraged following arthroscopic surgery of the lower limbs to aid circulation and return of normal function, within the limits of pain. Excessive stair-climbing or prolonged walking is not encouraged in the first few days after arthroscopic surgery of the lower limb.

Elevate the legs as much as possible with the help of a couple of pillows under the heel.

Physical Therapy

Depending on your needs, you may be referred to a physical therapist, a specialist in the rehabilitation of joints, who will aid in your recovery.   

Follow up visits

On your first follow up visit to the clinic after the surgery, the detailed nature of your surgery wILL be explained to you and the dressings will be changed.

You will be reviewed regularly following your initial visit.

Do let your doctor know if the limbs are persistently swollen and painful or if you have any chest pains or breathing difficulties.

Complications of Arthroscopic ACL Surgery

Swelling or Haemarthrosis

This is usually common and will subside fairly soon. In some patients the swelling may accumulate and cause pain in which case an aspiration of the joint may be indicated. Achieve knee extension as early as possible. Anti-inflammatory medication and rehabilitation helps in reducing this effusion.

Infection

This can occur following any surgery but it is less common following arthroscopic surgery. Nevertheless, it should not be taken lightly. The signs of infection are pain not relieved with usual doses of painkillers, redness and discharge from the surgical wound. If there is excessive staining or discharge from the wound you should contact your surgeon immediately.

Deep Vein Thrombosis

In this condition the leg tends to swell and calf pain may be present. It is common in certain population groups and high-risk patients include those with a past history of thrombosis, pulmonary embolism, strong family history, clotting disorders, contraceptive medication and prior venous disorders amongst other causes. If you are concerned you should contact your surgeon and a Duplex scan or a venogram may be necessary to confirm the diagnosis prior to treatment.  The best way to prevent this complication is to move the limbs as soon as possible following surgery and do the exercises suggested to prevent swelling of the lower limbs would also be helpful in decreaing the incidence of this condition.  This can be fatal in a small percentage of patients, though the incidence is rare.  Fraxiparine, a blood thinner, would be given at the end of surgery.

Muscle Wasting

This is a real problem follwing ACL surgery and one needs to move the knee early to prevent significant wasting.  Physiotherapy will assist in speedier recovery.

Degenerative Arthritis

This is inevitable following an ACL injury and the severity varies with the extent of initial damage and time delay to surgical reconstruction.  Leading a healthy lifestyle with moderate level of activity would limit the amount of damage to the knee.  High impact activities would aggravate the degeneration.

Laxity of ACL graft and Instability

Despite surgery, the knee may continue to be weak or unstable.  This depends on the extent of injuries.  If a meniscectomy is warranted, it contributes to further instability and wear and tear in the long-term.  There is a 10 - 15% chance of requiring further surgery following an ACL reconstruction for young and active patients.  The ACL graft may also stretch over a period of a year.

Numbness and Sensory Disturbances

The joints are richly supplied with nerve endings and sometimes, it is inevitable that during surgery, there may be some damage to these nerves despite adequate precautions.  This may result in patchy numbness around the operated area.  This will generally recover fully but in some patients, the numbness may take a long time to resolve or remain permanent.  This is particularly common following ligament reconstruction and meniscal repair surgery.

Mechanical Problems

Sometimes patients develop complications from screw impingement, migration and recurrent synovitis.  This may require repeat surgery in a small percentage of patients. The healing of the grafts may also be sometimes affected this may delay recovery.  Loss of motion can be a problem with ACL surgery and this can be prevented by early mobilization and emphasis on achieving extension as soon as possible.

Loss of Knee Range of Motion

Following any type of knee surgery, the joint can experience a decrease in its range of motion, especially extension or ability to straighten the knee.  It is very important to achive fully extension as early as possible after knee surgery by folowing rehabilitation advice closely.