ACL Step by Step

STEP-BY-STEP ACL RECONSTRUCTION- Steve A. Mora, MD

	MRI (side view of knee) showing the ACL rupture and blood in the knee.		Inside the knee prior to the reconstruction. The ACL is ruptured.
	The Notchplasty: widening of the ACL .		The 10mm Tibial Tunnel below.
	Preparing to make the femoral tunnel above: 7 mm offset guide then 9 mm drill.		Notice the tunnel below and above. The new graft will be resting tightly in these tunnels.
	Passage of the new ACL graft by using the sutures tied to the end of the top bone plug.		The graft is about to be passed. The suture holding the graft is visible as it is pulled upward.
	New ACL Graft within a protective sheath, in place within the tunnel above and below. Next are the screws which act as threaded dowels squeezing the graft against the tunnel walls.		Insertion of the 2 Biologic screws. These will dissolve after 2 years.
	7x23 bio-absorbable screw in the femur. The tibial screw is then placed below to secure graft on both ends.		New ACL graft in place. Ready for rehabilitation.

After Surgery

The surgical procedure takes about 2-2.5 hours, depending on the graft choice and on whether other tears exist. Allograft ACL grafts are about 20 minutes faster. A typical stay at the surgical center might be 4 hours. Patients receive their pain medication and antiinflammatory prior to the day of surgery. In some cases a total leg anesthesial block is done to help with post-op pain.

It is important to rest for the first 3 days after surgery so that swelling could be limited. A motion machine is started the first week. Home exercises are started right away.

Overall, the strategy for optimally controlling pain calls for adhering to many small details. First is a thorough pre-operative briefing so patients understand exactly what is going to happen to them, and what they are supposed to do, including exactly what medications to use, in what doses and combinations, and when. Meticulous surgical technique is employed at all times so that the post operative pain can be diminished. The best way to deal with minor to moderate pain is with feedback, deep breathing and re-focusing the mind. For more sever pain, there are 3 key medications which we use in combination, each operating by a different mechanism, so the effects are complimentary and synergistic.
Tylenol XS 1000mg three times a day (over the counter)
Prescription anti-inflammatory (usually Vioxx, Celebrex or Bextra)
Synthetic narcotic (Norco or Vicodin). The more narcotics you take the higher the chance for nausea and constipation.

Dr. Mora may give you a total leg anesthesia block so that you are very comfortable during the expected pain peak the first day and one half. You may also be given an anti-nausea medication before you are discharged. You may also want to have a over the counter sleeping medication such as Benadryl 50 mg to take at night as needed for insomnia. Most patients do excellent with their discomfort and report good pain control without the use of the synthetic narcotics.

The first follow-up visit is usually within 5-7 days. PT is ordered at the first visit. The home exercises will continue daily.

And now its off to the races......

Good luck with your surgery.