Anterior Cruciate Ligament Reconstruction
Anterior Cruciate Ligament (ACL) Reconstruction Surgery is performed to reconstruct this small but
important ligament at the knee's center and restore stability. To reconstruct the ACL, Dr. Sanders
rebuilds the ligament with a graft consisting of bone from the patella (kneecap), a portion of patella
tendon, and some attached bone from the upper portion of the leg. There are several graft options
available for this procedure - grafts taken from the strong, uninjured leg; grafts taken from the
ACL-affected leg; and grafts taken from a cadaver. Those grafts harvested from the patient's own
tissues are called Autografts. And those taken from a cadaver are called Allografts. All graft
options are effective in the right patient. Though, an Autograft from the patient's own knee is
the most effective. The graft site, whether the affected ACL leg, or the unaffected opposite knee,
will however require some rehabilitation. While no rehabilitation is required on an unaffected,
opposite leg when an allograft is used, the allograft tissue inserted into the knee as a cruciate
ligament is not as strong as autograft tissue.
Recent studies have shown that there is almost a 25% failure rate in ACL reconstruction in patients
under the age of 40 using allografts compared to only a 4-5% failure rate using bone-patellar tendon-bone
autografts. This means that there is more than a five times greater chance that the patient who selects an
allograft will have to have more surgery on their leg. Despite proponents of allograft reconstructions
believing that allografts represent the most minimally invasive option, we believe that at the end of the
day it is anything but that. At minimum, there exists a 40% chance of a patient having to undergo one or
more repeated operations on the knee when the need to bone graft tibial and femoral defects from the first
surgery, and failures of the second reconstruction are calculated in. Because of this, we also believe that
these allograft reconstructions, in fact, represent the most invasive option available.
Doctor and patient must jointly decide the best graft source based on the patient's level of activity and
lifestyle. For elite athletes, weekend warriors, and ordinary folks, Dr. Sanders has found that grafts taken
from the uninjured leg facilitate the most rapid recovery to a preinjury lifestyle as well as athletic activities,
because the limbs of these patients respond better to a rehabilitation program designed for two moderately affected
legs rather than a lengthier rehabilitation program for a single leg recovering from an ACL Reconstruction and graft
harvesting. The vast majority of patients with an autograft taken from the healthy leg can return to competitive sports
by three months after surgery.
Those patients with less active or sedentary lifestyles may prefer one of the other graft options - such as an allograft
from a cadaver, or an autograft from the same knee. Decisions must be individualized and must incorporate the patient's
age, activity level, and personal preferences.
However, at the end of the day, research has shown that over 95 percent of ACL reconstructions using an athlete's own
tissue survive, as opposed to the 75 percent reported in allograft reconstructions. For this reason Dr. Sanders refuses
to perform allograft procedures on athletic people or on anyone under the age of 40. Dr. Sanders carefully decides which
cases are accepted at the Sanders Clinic, and he refuses to perform a procedure that he believes is not in his patient's
best interest.
A similar incision is made into the front of the graft leg.
Instruments are used to harvest a portion of the kneecap, intervening patella tendon, and bone from the upper portion
of the graft leg. The graft is removed and this wound is closed. Drill holes are made in the harvested bones for
placement of strong sutures. When the ACL knee is used for the graft harvest, the same skin incision is utilized
for both procedures. When an allograft is utilized, a much smaller incision is made. Clearly, when an autograft
from the injured knee or an allograft is employed, there is no need to rehabilitate the unaffected, opposite leg.
The graft harvested from the graft leg is then placed through the ACL knee,
and the sutures are tied over buttons that very rarely need to be removed. Occasionally, the sutures are
tied over a screw and washer on the thigh. Previously interference screws placed into the drill holes were
used but were found to cause a number of problems. They often required removal, particularly on the tibia.
They left holes in the bone and would require bone grafting if revision surgery was indicated. These screws
also had the potential to make the graft too tight and thus "capture the knee," preventing patients from regaining
normal Range of Motion (ROM). The wounds are then closed over drains, which prevent excessive fluid from accumulating
inside of the knee joint and under the skin. This reduces the postoperative pain and facilitates a rapid return
to normal function. A light dressing and compressive stocking are then applied to one or both legs, depending on
the graft option selected. And a Cryo/Cuff® is placed on both knees for cold
and further compression.
Read About the Rehabilitation Roadmap.
