So you may know what a ACL or anterior cruciate ligament is, and you may even have a rough idea of what the operation entails, but what will actually happen to you from coming in to the hospital in the morning to being discharged. It is a scary situation. Most people have never had an operation or been an inpatient before. So lets get started.
When you get added to the list for your surgery, we will contact you to arrange a date that is suitable for yourself. On that day you will need to be fasted which means nothing to pass your lips that is not water from midnight the night before (min 6 hours) Water is ok up to 2 hours before surgery, but its best to wait until the anaesthetist has seen you on the morning of surgery to let you know when you can drink water until.
You will be in the day surgery unit in an individual room to allow you to relax before surgery. The anaesthetic consultant will come in and have a chat regarding your health and any previous medical problems, or allergies that might change what we do for you.
The nursing staff will then ask you to get ready for theatre by giving you a hospital gown.
Mr Frame will then see you and have a chat to make sure you are happy with what is happening and that any questions regarding the surgery or after care is answered. He will then go through the consent process for theatre. This has already been covered in the clinic on booking you for your surgery, but we go through things again to refresh your memory and to address any concerns you have. The forms are then signed and an arrow is placed on the leg the surgery is taking place.
You will then when theatres are ready, walk you down to the theatre suite and in to the anaesthetic room, where you will be introduced to the rest of the team carrying out your surgery and the process for anaesthetic will take place. Normally with an ACL a general anaesthetic will be used. This is often supplemented to make you more comfortable post op with a nerve block. This is a small injection of some local anaesthetic around one of the small nerves in the leg just above the knee that numbs the knee itself for about 6-10 hours. This is often done with ultrasound guidance to help make sure it is as effective for you as possible.
Once you are comfortable and asleep, you are taken through in to the main operating room, where we place a tourniquet above to knee to make the surgery bloodless.
The surgery takes approx 40 minutes to an hour for an ACL reconstruction or an ACL repair.
If you are having an ACL reconstruction or and ACL repair, we examine your knee with you asleep and confirm the instability. We then do a further check to make sure you are you and we are doing the correct operation on the correct side and check all the equipment and the MRI scan are on large screens in theatre to help with the surgery.
Your leg is then placed in the correct position for surgery flexed at approx 90 degrees and held in position with supports.
The anaesthetic team then give you antibiotics to reduce your risk of infection.
We then clean and prepare the skin to make sure it is sterile. We use ChoraPreps which use chlorhexidine to sterilise. We then drape the area to maintain the sterile field.
With an ACL reconstruction we first make a small incision to the top and inside part of the leg to take one of the hamstring tendons – semi-tendinosis. As we do the innovative Arthrex all inside technique we do not need to use the other hamstring tendons like the traditional ACL reconstruction techniques, reducing your pain and leaving your hamstrings stronger. This small tendon approx 250mm long is then fashioned in to the new ACL graft by folding it twice and quadrupling the stands. This ultimately ends up approximately 65mm long and 8.5mm in diameter, perfect for reconstructing your ACL. Tis is then placed in a small plastic tube that matches the size of the graft to compress it and make it perfectly uniform in size. These are called Arthrex Graft Tubes.
Using small cuts at the front of the knee joint of only 4mm we can place a camera in to the knee joint and look at the articular surface of the knee and the meniscus and the damaged ACL. If we are doing an ACL repair using the Arthrex Internal Brace, we do not need to take any of your hamstrings. We would identify if the ACL is in good condition and has pulled off from the femoral side of the joint. If so and we can repair it we use a special instrument to pass two sutures through the ACL and then drill a small 4.5mm tunnel where the ACL was originally attached. these sutures are then passed through this bony tunnel. We then Drill another 4.5mm bony tunnel in the shin bone (tibial) side where the ACL originates from.
Though this we can pass the internal brace and then pass it again through the femoral tunnel with the sutures holding the ACL back to where it was pulled off. We also make some small holes to allow stem cells in to the knee joint to help heal the ACL. The internal brace is like a seatbelt supporting the knee and providing stability as the original ACL heals back to where originally was. The Internal brace is then secured with an Arthrex Swivel lock which is a small peak (a type of special plastic) screw. The small holes we have made in the skin are then closed with absorbable sutures and the skin glued to make the wounds watertight and dressed with a transparent dressing to keep things as sterile as possible.
If we are carrying out an ACL reconstruction, the old ACL has to be trimmed away and we use a special small shaving device only 4.5mm in diameter. Once the ACL has been removed we then drill 2 small tunnels to accept the new graft. These tunnels are drilled using a special drill called a FlipCutter. this allows us to place the position of these tunnels as accurately as possible, and in the exact position of your original ACL so it functions as well as possible. This is called an all inside anatomical ACL reconstruction. once the tunnels are created we then pass the new ACL graft we created earlier from your hamstrings in through one of the small holes we used to put the camera in. The graft is then secured in the tunnels and tensioned after testing the movement of your knee through a full range of flexion and extension. The graft is secured using 2 small titanium buttons called a tightrope RT. These are very secure and strong and stronger than the traditional screw fixation.
The wounds are all then cleaned and closed with absorbable sutures, glue on the skin and clear dressings to keep things as clean and sterile as possible. We inject local anaesthetic in to the wounds to make things as pain free as possible. The leg will then we wrapped in fluffy wool and a bandage. The tourniquet will be released. and you will be started to be woken up by the anaesthetic team and transferred to the recovery suite where you will be looked after on a 1 to 1 to keep you as safe as possible. Once you are awake and we are happy you are as pain free as possible we transfer you back to the ward in to your room.
The physio team will then introduce themselves and begin the rehab straight away. Teaching you haw to use crutches safely and mange the stairs. Normally you would be up and mobile very quickly. We would anticipate you getting away the same day from your surgery.
Physio will make arrangements for your rehab over the next 6-9 months back to sport.
You will have a wound review at 2 weeks.
We give you TED socks that you have to wear for 6 weeks to reduce your risk of getting a DVT (deep vein thrombosis).
We see you back in the clinic at 6 weeks, and at this point if you have had an ACL reconstruction you should have excellent range of motion, no pain and are feeling more stable and carrying out all your normal day to day activities. You often still have some swelling which is totally normal. It can take up to 3 months for the swelling to go down completely.
At 6 weeks for an ACL repair, you should be pain free with excellent range of motion, and minimal swelling, feeling very stable and getting back to your normal day to day activities.
At the 6 week appointment we take an X-Ray to confirm the position of the new ACL.
If at any point during this you need to contact us we are always available on firstname.lastname@example.org or on the phone.