The ACL (Anterior Cruciate Ligament) in the knee is very important for keeping it stable. This ligament joins the upper leg (femur) and lower leg (tibia) bones to each other. There are chances of an injury in the ACL while over-straightening of your knee, bending or twisting it, landing down incorrectly after a jump or while playing football. Women are more susceptible to contracting ACL injury.
Anterior cruciate ligament tear or damage is a common injury in young athletes and people who actively use the knees. Arthroscopic reconstruction of ACL is a popular surgical technique to repair the torn ACL. It is reported that patients undergoing this procedure are benefitted with 85-90% satisfaction with the restoration of functional stability and relief from the symptom.
What is ACL Ligament?
The ligament that is present in the center of our knee is called as anterior cruciate ligament or ACL. Four major ligaments hold the knee together, and the ACL is one among them. The ACL is damaged when it is twisted or injured. It is the site for one of the most common injury of the knee.
About half of the ACL injuries (knee injury) happen along with rupture of other knee structures like meniscus, cartilage and ligament. The ligament injuries are termed as sprains and are categorized into three grades:
- Grade-1 Sprain: Ligament is mildly damaged and stretched but retains the ability to keep the knee stable.
- Grade-2 Sprain: The ligament is stretched to the level of loosening. It is also referred as a partial tear of the ligament.
- Grade-3 Sprain: The ligament is torn completely into two parts, making the knee joint unstable.
What are the Common Causes ACL Injury?
Some of the common causes of anterior crucial ligament injury are:
- Rapid change of direction
- Stop suddenly
- Slow down during running
- Incorrect landing from a jump
- Direct contact like tackling in football
According to many researchers, it is found that female athletes are more prone to ACL injury than the males. The experts say that it is due to the difference in the structural integrity of muscular strengths, neuromuscular control, and physical conditioning. The differences in the pelvic and lower extremities may also contribute to the ACL injury.
What are the Symptoms of ACL Injury?
When you injure your ACL ligament, you may have the following possible symptoms:
- ‘Popping’ sound from your knee
- You knee cannot bear the strain from your weight
- Swelling within 24 hours
It is important to visit your doctor if you have a knee injury and notice the symptoms mentioned above. Though you may observe that swelling may subside on its own by taking rest, the moment you resume any heavy activity, exercise or any sports, the swelling and pain would reoccur. When left untreated, ACL tear can also lead to damage of the cartilage in your knee joint.
When the ACL is injured, you might hear a “popping” noise and may feel your knee give out from under you. Other typical symptoms include:
- Impact on even a simple motion
- Pain in the joint
- Difficulty in walking
How to Diagnose an ACL Injury?
The diagnosis of the anterior crucial ligament injury can be diagnosed in the following ways:
Physical Examination/Medical History:
When you visit your doctor, a physical examination is carried out to check the symptoms, movement and structure of the injured knee. A comparison is made with the good knee, and medical history is taken.
The doctor may ask you to do the test to confirm the diagnosis. Some of the important diagnostic tools used are;
- X-rays: It is advised to rule out if any broken bone is associated with the injury.
- MRI (magnetic resonance imaging) Scan: MRI gives the clear images of the structures of the soft tissues like ACL.
What are the Treatment Options for ACL Injury?
Treatment of ACL injury depends on patient’s requirement. Usually, there are non-surgical and surgical treatments available for anterior cruciate ligament injury. A patient who is active in sports or athlete, or who are placed in the high demands of the knee, would require surgery. The older patients, who are less active, can get back to the normal lifestyle without any surgical procedure.
Elderly patients, who have a low activity level of the knee, can be benefitted by non-surgical treatments. The doctors usually suggest simple treatment if the overall stability of the joint is good. Some of the non-surgical options are:
- Bracing: Bracing is good to protect the instability of your knee. For better protection, further, your doctor may give you crutches for some days to keep the weight off your leg.
- Physiotherapy: Once the swelling starts reducing, a rehabilitation program under an expert should be started carefully. This will help restore energy and strengthen the muscle of the knee.
According to a research article published in the Journal of Operative Techniques in Sports Medicine, it is mentioned that the surgeon should take care of few basic steps before and while doing an ACL reconstruction which includes pre-operative evaluation, selection of the patient, techniques of the procedure, and rehabilitation methods. This has been known to help achieve the expected outcome after the surgery.
There are various types of surgical treatment options available for arthroscopies, like patellar tendon graft procedure, Hamstring graft procedure, Allograft procedure, and ACL reconstruction. However, arthroscopic ACL reconstruction is the one which is suitable for most of the patients’ condition.
Arthroscopic ACL Reconstruction
Anterior cruciate ligament reconstruction is done to treat the damaged or ruptured anterior cruciate ligament of the knee. It is performed to replace the damaged ACL ligament by an artificial or self-tissue graft.
ACL reconstruction is one of the most common procedure performed by the orthopedic surgeons. Doctors recommend it fo the patients that have a high risk of further damage. This procedure can be carried out either as an open surgery or using an arthroscopic approach.
Read More: ACL Surgery Cost Details in Hindi
When is ACL Surgery Performed?
ACL reconstruction surgery is performed when the ligament is severely impaired, and conservative treatments do not help. For instance, when the anterior cruciate ligament is completely torn. ACL reconstruction is a minimally invasive procedure during which a surgeon makes a few small incisions and inserts surgical instruments and an arthroscope. When ACL ligament injury (complete or partial) is accompanied with other damages such as meniscus tear or a PCL tear, surgery may become necessary.
During an ACL reconstruction surgery, a surgeon removes the torn ACL and replaces it with a new tissue that can be taken from the patient’s patellar tendon or the hamstring or a donor’s tendon.
After this, the surgeon checks the strength of the graft to see whether it is strong enough to hold your knee together. The graft should remain stable even when the knee is bent or moved. Post this, the incisions are stitched up. The patient is then moved to the hospital ward for further recovery. The surgeon provides the patient with an ice water bandage to reduce swelling. The physical therapist creates a detailed recovery program for the patient for speedy and successful return to normal life. It is very important that the patient follows it meticulously.
During the rehabilitation, tendon used for a replacement goes through a process called liagmentization after the surgery, that refers to a slow process by which a tendon tissue changes its characteristic to become more ligament like.
The program may contain specific exercises for improving the life of the operated knee. The exercises facilitate improving your mobility, balance, strengthening the knee muscles and overall ability to walk normally. Again, the operated knee is likely to remain stiff for a few weeks; pain-killers then become a necessity.
Patients need to maintain their legs in a raised position while resting. The patient may also need to move around with the help of crutches for two weeks post surgery. The period you will take for returning to your work-life depends on the intensity of work you have. For instance, if you have a desk job, then the period is two weeks, similarly, if it is manual or sports related work, then the cooling off period is six months.
Your doctor may recommend some knee braces that help to keep the knee in immobile and help recover soon.
Read More: Comprehensive Guide for Donjoy Knee Braces
How Does a Tendon Graft Grow Into an ACL?
As mentioned above, anterior cruciate ligament (ACL) reconstruction surgeries employ tendon grafts, such as the patellar tendon or hamstrings tendon, following which a new ligament grows on the tissue graft.
The phenomenon of remodeling (or differentiation) of a tendon into a ligament is termed as “ligamentization”. Here, a question arises as to how a tendon graft grows into an anterior cruciate ligament? Before elaborating on the above question, let’s have a look at the differences between a tendon and a ligament.
ACL Reconstruction With Tendon Graft – Notable Differences
- Tendon is tough and inelastic in nature. A ligament is strong and elastic.
- In terms of structural properties, a tendon is modified white fibrous tissue. Ligaments are modified yellow elastic tissue and comprise of a few collagen fibers.
- Fibers are arranged in parallel bundles in tendons. In ligaments, fibers are densely placed but are not arranged in parallel bundles.
- With respect to function, tendons are tissues that connect muscles to bones. Ligaments are tissues that connect bones and helps in holding them at their anatomical positions.
The ACL reconstruction procedure was implemented on the basis of numerous animal studies which showed that the implanted tendons differentiated into ligaments, over time. However, biological changes and phases of ligamentization in humans have not been understood clearly.
In 2011, The American Journal of Sports Medicine published a literature review on “ligamentization” in human anterior cruciate ligament reconstruction surgeries.
It was found that a tendon graft undergoes a series of biological changes (collectively known as ligamentization), in the intra-articular (within the joint space) environment. Although ultrastructural variations were evident, histological similarities were found between mature tendon grafts and human anterior cruciate ligaments. However, the time taken by tendon grafts to remodel into mature ligaments could not be ascertained.
Additionally, the histological changes that occur in other autografts used in ACL reconstruction surgeries were not proven to be similar.
When compared to animal grafts, human tendon grafts was shown to take longer to remodel into mature ACL ligaments. Besides, animal grafts showed an early phase of necrosis, whereas significant signs of necrosis were not found in human grafts. Hence, it was concluded that the outcomes of animal ACL reconstruction grafts were not the same as those of humans.
It was proposed that the ligamentization process of an ACL reconstruction graft in a human knee needed further study. A clear knowledge of the phases of ligamentization would be helpful in determining the methods and duration of post-surgical rehabilitation and recommended time span after which a patient could resume their normal activities.
8 Important Steps Before Having ACL Surgery
- Talk to a doctor
- Get an x-ray and MRI
- Choose an experienced orthopedic surgeon
- Before surgery: Rehab/strengthen the knee as much as possible
- Graft and fixation choice: Choose the type of ACL surgery you want
- Assess the postoperative costs that are likely to be incurred including medicine and physiotherapy.
- If you have medical insurance Have a thorough conversation with your health insurance company to learn how much % your insurance will cover you. Fully document the questions, answers, and conversation.
- Now that you have cost information, you are able to make an informed decision on whether or not to have the surgery.
ACL Surgery Cost Breakdown
1. ACL Surgery Pre-Ops Costs
Pre-ops tests carried out for ACL surgery typically include the following:
Your surgeon may refer some diagnostic tests before ACL surgery. Some tests are necessary for all patients before surgery. Others tests are done only if you are at risk of certain health issues.
- Physical Examination
- Blood Test
- Chest x-ray
- Coagulation Test
Depending on the case to case basis, some tests may not be required. The average cost for pre-ops test can be expected between Rs 6000 to Rs 15000.
2. ACL Surgery Costs
The surgery cost typically includes the following.
- Surgeon’s Fee
- Anesthetic Fee
- Operating Theatre Charges
- Graft cost
- Cost of graft fixation screws/material
- Surgery Consumables
- Medicines for anesthesia
3. Costs After ACL Surgery
After the ACL surgery, one has to stay back in the hospital for at 2 days and undergo the postoperative surgery rehabilitation, which includes guided movement in the presence of a trained physical therapist, and pain-relief medicines. Costs incurred during this period are:
- Medicines for pain relief
- Rehabilitation and physiotherapy appointments
- Consumables (dressings, knee braces) and crutches cost
- Post-surgery Hospital Stay for self and companion if any
Variations in ACL Surgery Cost
It is a common experience that when one visits several hospitals, one can find a lot of variations in the quoted cost for ACL surgery. It can be confusing for an average patient to hear very different prices for the same procedure, but many times, there are genuine reasons for these variations.
ACL Surgery Cost in India
The cost of ACL reconstruction surgery in India ranges between Rs 75,000 to Rs 1.5 lakhs and varies with the type of procedure, surgeon, and quality of graft, method of fixing the graft, facility. Following the surgery, additional costs of Rs 15,000 to Rs 20,000 may be incurred in treatments such as post-surgery physiotherapy, which is essential for a good recovery.
How to Manage the ACL Surgery Costs?
Let’s take, for instance, a patient finds it hard to afford the projected cost but is reluctant to compromise on quality and a successful outcome, what are the options?
1. Find a Good Orthopedic Surgeon Who is Not Super-Expensive
There are many ways to locate highly qualified doctors who are as qualified and experienced as the most sought after specialist in your city, but not so expensive.
2. Select a Graft Which is Optimal For You
Choosing the right graft for ACL reconstruction depends on several factors such as age, functional demands, and pre-existing anterior knee pain. Discuss what option will be most suitable for you.
3. Evaluate and reduce avoidable expenses
Do you need to have a private room and a full-time nurse? Can you consider undergoing your ACL surgery by an expert doctor in a hospital that does not provide luxury services like five-star hotels?
4. Prepare Yourself for Surgery
You may be able to help yourself greatly by preparing yourself for surgery, both physically and mentally. Few helpful tips include engaging in pre-operative physiotherapy; taking a balanced diet; maintaining blood-sugar levels, in case you have diabetes; and quitting smoking.
5. Medical Insurance
If you already have medical insurance, then the good news is that most of the medical insurance companies in India now cover ACL surgeries. Patients need to talk to their surgeon beforehand and acquire all the essential documents. Authorization from the medical insurance company is required before you schedule your surgery, for them to validate the claim.
It may be prudent to find out, how much of the cost will they reimburse. Although it might not be the total amount, it surely makes the treatment affordable.
How to Decide You Need an ACL Surgery?
Okay, so you have been informed by your orthopedic doctor that you have suffered from an ACL tear. Let’s assume you have been advised to undergo an ACL surgery.
How would you go about deciding whether to go ahead or not? Whether it be a minor surgery or a major one, deciding to undergo any surgery is not easy. The fact that you are already stressed out and cannot think about it with a clear head makes it all the more difficult.
So, here are few simple pointers to make an intelligent and informed decision about it.
1. Never Rush
An ACL Injury, howsoever bad, or even a complete tear does not warrant an immediate corrective surgery. As long as you keep yourself away from getting injured again, and do not stress your knees further, it is completely safe to wait weeks and even months before you decide to go under the knife. If you come across a health worker or specialist who seems to be rushing you into making a decision, take a breather and politely excuse yourself.
2. Exhaust Conservative Approaches
There is a lot of conflicting medical evidence for and against using an ACL surgery as an intervention for handling ACL tear. However, the golden rule that if it ain’t’ break; don’t fix it still holds true. How do you know that your ACL is so torn that only surgery can fix it? None of the routine tests including the MRI and clinical examination is a full-proof mechanism to determine that you have such a bad ACL tear that nothing but surgery can fix.
Have you given enough effort to recuperate from the injury by undergoing physiotherapy under an expert supervision? It may be wise to give at least few months with regular physiotherapy and exercise and record the symptoms with regards to stability of the knee.
If it turns out that the routine physiotherapy and exercise is improving your knee function, you can probably skip the surgery altogether.
3. Watch Your Symptoms
An ACL tear, whether partial or complete, would typically result in episodic occurrences of knee instability. There is no strong correlation between the extent of the tear and the amount of instability experienced, as it varies a lot from person to person. A person with just a partial tear, which may heal on its own, may also express knee instability, whereas in some rare cases, a person with a complete tear may not report any instability issues.
Each time you experience any unstable movement such as a feeling of forward slip of your tibia (below knee joint), or an abnormal pivot or rotation of the knee, make a note of it. Over time, observe whether the stability is getting worse or improving gradually.
4. Confirm Your Diagnosis
Use a combination of clinical examinations, MRI report and awareness of your knee stability to zero on the fact that you may be suffering from a serious ACL tear.
Relying on one indication alone is prone to error because MRI report and even a clinical examination carried out by an expert can be in error. [1, 2, 3]
The benefit of combining multiple inputs can help by reducing the error chances. If the MRI report, clinical examinations, and your knee stability experiences do not match, you need to assess further if you have a real strong case to undergo an ACL surgery.
5. Evaluate Your Future Needs After ACL Surgery
What future you have in mind vis-à-vis your knee function is crucial to taking a decision on ACL surgery. Are you planning on continuing with any high-impact sports? Can you switch to any low-impact activity? Does your lifestyle expose you to further chances of similar injuries? Do you need to get your knee fixed soon so you would not lose out in your sports career? The cost of surgery is also an important consideration for many.
A professional athlete who is likely to return to high-impact sports may be better off undergoing the ACL surgery, as medical evidence suggests a strong chance of further injury if the knee instability has not been taken care of. If one experiences a regular pattern of instability despite engaging in normal activities, it is definite cause for concern.
On the other hand, a person who does not foresee any such need or participation in high-impact sports, and does not exhibit any signs of instability may think again about having an ACL surgery.
While the above list is not an exhaustive list of points to consider before a decision is made, a detailed pros and cons analysis that is specific to your medical condition can lead to a much better decision on not only whether you should undergo an ACL surgery, but also of what type. There is a lot of content available in the internet that can help raise awareness. However, what is most lacking is the guidance on how relevant the information is as per one’s specific medical case. That is where a guidance provided by independent and unbiased medical experts who want you to take the best decision can be most helpful.
Common Complications After ACL Reconstruction
A study published in the Journal of European Radiology, says that some of the common complications may occur after ACL reconstruction, however, they are very rare. So, it is important for you to understand the risks and complications before undergoing the procedure to make a well-informed decision about the surgery. As is true with any surgery, it is always advisable to have a few more opinions before undergoing any surgery, even a relatively safer surgery such as the ACL reconstruction.
The complications of ACL reconstructions are discussed below:
Graft Impingement occurs if the graft gets trapped in the notch between the rounded ends of the femur (thigh bone). It can lead to the abrasion, wear and tear of the graft, causing graft failure. As a result, it obstructs the joint movement, and the patient suffers from decreased range of motion.
Graft failure occurs due to the graft impingement.However, if the graft is ruptured, it can be revised by using the tendon of the other leg.
Tibial Tunnel Cyst
A Tibial tunnel cyst is a rare complication, which is attributed due to some errors like allograft tissue necrosis, incomplete incorporation of graft tissue, resulting in flowing of the joint fluids into the tunnel.
Arthrofibrosis is a common complication of ACL reconstruction. It is characterized by formation of excessive scar tissues within the joint and surrounding soft tissue spaces, causing pain and limits the range of motion
Postoperative infections are seen in approximately 1 in 200 cases of reconstruction. The infection can be managed by antibiotics orally or by drip. Very rarely, further surgery is done to wash out the infection. Infection leads to pain and swelling, which impacts the motion.
Allergic Reaction to Drugs
Blood transfusion related complications like heart attack, pneumonia, renal failure, infection of the bladder are reported in some patients. Nerve blocks (anesthesia) related complications like nerve damage, the infection can also happen. Underlying serious health issues may also cause complications, which require prolonged hospitalization.
Deep Vein Thrombosis
Sometimes, the blood clots are formed in the veins of the leg. In such conditions, your doctor may prescribe you some anti-clotting drugs or medications, which helps in thinning the clots and removes the obstruction in the vein. The anti-clotting medications are available in the form of tablet or injections. Somehow, if these clots go to the lung, it can cause difficulty in the breathing.
Stiffness In The Joint
It occurs due to the formation of the scar tissues within the joint. It can be minimized by rapid rehabilitation or advances in the operative technique. However, a full range of motion may not be achieved.
Donor Site Problem
Donor site referred as the place from where the graft is taken. Usually, the graft is taken from hamstrings or patella for ACL reconstruction. So, the patients may have pain and swelling in these areas, which subsides with time.
Damage To The Vessels
The surgeon should avoid damaging the small nerves present under the skin during the procedure. Sometimes, they get cut during the procedure and causes numbness in the area, which is minimized with time, and does not cause any functional problem of the knee. In case, if any significant nerve gets cut, it can cause weakness in the leg.
Excessive Swelling & Bruising
The patient may experience excessive swelling and bruising in the soft tissues of the knee, but it typically disappears with time.
Problem With The Hardware
In anterior cruciate ligament reconstruction, some hardware devices like screws and staples are used to fix the grafts to the bone. This can lead to irritation or inflammation of the wound. In such cases, screws or staples are removed once the grafts has begun to grow into the bone.
The patients may have if there is any damage to the other structures of the knee.
Reflex Sympathetic Dystrophy
It is a very rare complication and characterized by excessive and unexplained pain.
- The ACL or anterior cruciate ligament reconstruction requires a maximum one-day hospital stay. During that period, you may be given painkiller in tablet or intravenously (drip).
- If there is any fluid accumulated, it is drained from the knee.
- Your doctor may give you a splint to make the recovery comfortable for you.
- A physiotherapist can demonstrate light exercises that can be done at home.
- Do not touch any waterproof dressing unless your doctor advise.
- Take ice therapy for 20 minutes over the knee; repeat it frequently.
- Contact your doctor if you notice any symptoms like pain, redness, swelling without any delay.
- Postoperative follow-up with your doctor should be done after 7 days.
Physiotherapy is one of the most integral parts of ACL reconstruction. In the case of ACL reconstruction, preoperative physiotherapy works excellent in preparing your knee for the procedure.
After surgery also, you should continue the physiotherapy under the supervision of an expert. The activities like cycling can be done at 2 months, and jogging can be done at 3 months after the surgery. With adequate fitness, confidence, and training, one can return to the sports. For professional sportsmen, it takes 6-12 months to go back to the activities depending on the rehabilitation and the other factors.
The optimum success of the procedure and the rehabilitation therapy sometimes get affected if the other structures of the knee such as articular cartilage, meniscus are also injured.
ACL reconstruction is considered as one of the successful procedure performed by the orthopedic surgeons. The procedure can give you even 99% satisfactory result if you get it done by a skilled and experienced surgeon. The procedure is highly demanded for the people who wish to get back to the active lifestyle, particularly who are very much interested in sports including running.
If ACL surgery cost is the primary consideration that is coming in the way of your aspirations to live a pain-free and active life, a little effort can help you find an optimal treatment option that does not compromise on quality and care. For more information, do get in touch with us through email at [email protected] or message us on WhatsApp at +91-9640378378.
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Dr. Kaleem Mohammed graduated as a Bachelor of Physiotherapy in 2014 from Deccan College of Physiotherapy, affiliated to Dr. N.T.R. University of Health Sciences, Vijayawada, India. Dr. Kaleem is an expert at handling physiotherapy needs of patients suffering from orthopedic and spinal conditions and post-surgery rehabilitation. Dr. Kaleem is associated with HealthClues since its inception where he facilitates diagnosis and advanced consultation with senior doctors. He is also a medical researcher and prolific writer who loves sharing insightful commentaries and useful tips to educate the patient community about fitness, treatment options, and post-treatment recovery.