Knee Ligament Repair

(ACL Repair, ACL Reconstruction, PCL Repair, PCL Reconstruction, MCL Repair, MCL Reconstruction, LCL Repair, LCL Reconstruction)

Procedure Overview

What is knee ligament repair?

Ligaments are bands of tough, elastic connective tissue that surround a joint to give support and limit the joint's movement. When ligaments are damaged, the knee joint becomes unstable. The ligament damage often occurs from a sports injury. A torn ligament severely limits knee movement, resulting in a person’s inability to pivot, turn, or twist their leg. Those individuals who cannot return to normal activities with medical treatments for a torn ligament may have the ligament repaired with surgery.

Other related procedures that may be used to help diagnose knee disorders include x-ray, joint aspiration, bone scan, magnetic resonance imaging (MRI), computed tomography (CT scan), arthroscopy, and arthrography. Please see these procedures for additional information.

Anatomy of the knee:

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Joints are the areas where two or more bones meet. Most joints are mobile, allowing the bones to move. Basically, the knee is two long leg bones held together by muscles, ligaments, and tendons. Each bone end is covered with a layer of cartilage that absorbs shock and protects the knee.

There are two groups of muscles involved in the knee, including the quadriceps muscles (located on the front of the thighs), which straighten the legs, and the hamstring muscles (located on the back of the thighs), which bend the leg at the knee.

Tendons are tough cords of tissue that connect muscles to bones. Ligaments are elastic bands of tissue that connect bone to bone. Some ligaments of the knee provide stability and protection of the joints, while other ligaments limit forward and backward movement of the tibia (shin bone).

The knee consists of the following:

• tibia - shin bone or larger bone of the lower leg.
• femur - thighbone or upper leg bone.
• patella - kneecap.
• cartilage - a type of connective tissue made up of cells and fibers that covers the surface of a bone at a joint. Cartilage is wear-resistant and helps reduce the friction of movement within a joint.
• synovial membrane - a tissue that lines the joint and seals it into a joint capsule. The synovial membrane secretes synovial fluid (a clear, sticky fluid) around the joint to lubricate it.
• ligament - a type of tough, elastic connective tissue that surrounds the joint to give support and limits the joint's movement.
• tendon - a type of tough connective tissue that connects muscles to bones and helps to control movement of the joint.
• meniscus - a curved part of cartilage in the knees and other joints.

What are the ligaments of the knee?

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There are four major ligaments in the knee. The ligaments in the knee connect the femur (thighbone) to the tibia (shin bone), and include the following:

• anterior cruciate ligament (ACL) - the ligament, located in the center of the knee, that controls rotation and forward movement of the tibia (shin bone).
• posterior cruciate ligament (PCL) - the ligament, located in the center of the knee, that controls backward movement of the tibia (shin bone).
• medial collateral ligament (MCL) - the ligament that gives stability to the inner knee.
• lateral collateral ligament (LCL) - the ligament that gives stability to the outer knee.

Reasons for the Procedure

The anterior cruciate ligament (ACL) is located toward the front of the knee. It is the most common ligament to be injured. The ACL is often stretched and/or torn during a sudden twisting motion (when the feet stay planted one way, but the knees turn the other way). Skiing, basketball, and football are sports that have a higher risk of ACL injuries.

The posterior cruciate ligament (PCL) is located toward the back of the knee. It is also a common knee ligament to be injured. However, the PCL injury usually occurs with sudden, direct impact, such as in a car accident or during a football tackle.

The medial collateral ligament (MCL) is located on the inner side of the knee. It is injured more often than the lateral collateral ligament (LCL), which is on the outer side of the knee. Stretch and tear injuries to the collateral ligaments are usually caused by a blow to the outer side of the knee, such as when playing hockey or football.

Early medical treatment for knee ligament injury may include, but is not limited to, the following:

• rest
• ice pack application (to reduce swelling that occurs within hours of the injury)
• compression (from an elastic bandage or brace)
• elevation
• pain relievers

A knee ligament tear may be treated with the following:

• muscle-strengthening exercises
• protective knee brace (for use during exercise)
• activity limitations

Knee ligament repair is a treatment for a complete tear of a knee ligament that results in instability in the knee. Persons with a torn knee ligament may be unable to do normal activities that involve twisting or turning at the knee. The knee may buckle or “give-way.” If medical treatments are not satisfactory, ligament repair surgery may be an effective treatment.

The surgery to correct a torn knee ligament involves reattaching the torn ends of the ligament or replacing the ligament with a piece of healthy tendon. A tendon from the kneecap or hamstring, for example, is grafted into place to hold the knee joint together. The tendon graft may come from the person (autograft) or from a cadaver (allograft).

There may be other reasons for you physician to recommend a knee ligament repair.

Risks of the Procedure

As with any surgical procedure, complications can occur. Some possible complications may include, but are not limited to, the following:

• bleeding
• infection
• blood clots in the legs or lungs

Some individuals experience pain, limited range of motion in the knee joint, and occasional swelling in the knee after surgical ligament repair. Others have increased motion in the knee joint as the graft stretches over time.

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Before the Procedure

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
• In addition to a complete medical history, your physician may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.
• Notify your physician if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general).
• Notify your physician of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
• Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
• If you are pregnant or suspect that you are pregnant, you should notify your physician.
• You will be asked to fast for eight hours before the procedure, generally after midnight.
• You may receive a sedative prior to the procedure to help you relax. Because the sedative may make you drowsy, you will need to arrange for some to drive you home.
• You may meet with a physical therapist prior to your surgery to discuss rehabilitation.
• Arrange for someone to help around the house for a week or two after you are discharged from the hospital.
• Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

Knee ligament repair may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your physician’s practices.

Knee ligament repair may be performed while you are asleep under general anesthesia, or while you are awake under spinal anesthesia. If spinal anesthesia is used, you will have no feeling from your waist down. Your physician will discuss this with you in advance.

Generally, knee ligament repair surgery follows this process:

1. You will be asked to remove clothing and will be given a gown to wear.
2. An intravenous (IV) line may be started in your arm or hand.
3. You will be positioned on the operating table.
4. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
5. The skin over the surgical site will be cleansed with an antiseptic solution.
6. The physician will make several small incisions in the knee area.
7. The physician will perform the surgery using an arthroscope (a small tube-shaped instrument that is inserted into a joint). The physician may reattach the torn ligament or reconstruct the torn ligament by using a portion (graft) of the patellar tendon (that connects the kneecap to the tibia), the hamstring tendon (from the back of the thigh), or other autografts. The tendon graft may come from the person (autograft) or from a cadaver (allograft).
8. The physician will drill small holes in the tibia and femur where the torn ligament was attached.
9. The physician will thread the graft through the holes and attach it with surgical staples or screws. Bone eventually grows around the graft.
10. The incision will be closed with stitches or surgical staples.
11. A sterile bandage/dressing will be applied.

After the Procedure

After the surgery you will be taken to the recovery room for observation. Your recovery process will vary depending upon the type of anesthesia that is given. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room or discharged to your home. Knee ligament repair is usually done on an outpatient basis.

You may be given crutches and a knee immobilizer before you go home.

Once you are home, it is important to keep the surgical area clean and dry. Your physician will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up office visit.

Take a pain reliever for soreness as recommended by your physician. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.

To help reduce swelling, you may be asked to elevate your leg and apply an ice bag to the knee several times per day for the first few days. Your physician will arrange for an exercise program to help you regain muscle strength, stability, and range of motion.

Notify your physician to report any of the following:

• fever
• redness, swelling, bleeding, or other drainage from the incision site
• increased pain around the incision site

You may resume your normal diet unless your physician advises you differently.

Because of the limited mobility, it may be difficult for a few weeks to resume your normal daily activities. You may need someone at home to assist you. You should not drive until your physician tells you to. Other activity restrictions may apply. Full recovery from the surgery and rehabilitation may take several months.

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.