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 may become unstable. Ligament damage often happens from a sports injury. A torn ligament severely limits knee movement. This results in the inability to pivot, turn, or twist the leg. Surgery is a choice to repair a torn ligament if other medical treatment is not effective.
Four major ligaments in the knee
There are 4 major ligaments in the knee. The ligaments in the knee connect the femur (thighbone) to the tibia (shin bone) which 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.
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How are knee ligaments injured?
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 happens 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.
What does a Knee Ligament Injury feel like?
You may have:
. Pain, often sudden and severe
. A loud pop or snap during the injury
. Swelling within the first 24 hours after the injury
. A feeling of looseness in the joint
. Inability to put weight on the joint without pain, or any weight at all
These injuries need medical attention. In some cases, as with ACL tears, you may need surgery so that your knee will be stable and won’t give out when you twist or pivot.
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Will I Need Surgery?
Only your doctor can tell you for sure. Though there can be exceptions, most collateral ligament tears (LCL and MCL) don’t need surgery.
However, when a cruciate ligament (ACL or PCL) is completely torn or stretched beyond its limits, the only option is reconstructive knee surgery. In this procedure, a surgeon will take tendons from other parts of your leg or from a cadaver to replace the torn ligament.
A ligament reconstruction for an ACL or PCL injury is complicated and involved. It's not the right choice for everyone. A person who has knee pain or severe instability may choose to have it. So might an athlete who wants to regain her level of performance.
But if the pain is not a problem, you may choose to skip the surgery and accept the risk of some lifelong instability in your leg. You may also opt for a custom-made brace. Talk about the treatment options with your doctor.
How do I get ready for a knee ligament repair?
. Your healthcare provider will explain the procedure to you and offer you the chance 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 healthcare provider may perform a complete physical exam to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.
. Tell your healthcare provider if you are sensitive to or are allergic to any medicines, latex, tape, and anesthetic agents (local and general).
. Tell your healthcare provider of all medicines (prescribed and over-the-counter) and herbal supplements that you are taking.
. Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medicines, aspirin, or other medicines that affect blood clotting. It may be necessary for you to stop these medicines before the procedure.
. If you are pregnant or suspect that you are pregnant, you should notify your healthcare provider.
. You will be asked to fast for 8 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 on your medical condition, your healthcare provider may request other specific preparation.
Your doctor will give you a physical exam. If your knee is very tense and swollen with blood, your doctor may use a needle to drain it. You may need X-rays to make sure you don’t have a broken bone, as well as an MRI to check on any ligament injuries.
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Risks of knee ligament surgery
As with any surgical procedure, complications can happen. Some possible complications are as follows:
. Blood clots in the legs or lungs
. Continued knee laxity or stiffness
. Continued pain/dysfunction
Some people may 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 on your specific medical condition. Be sure to discuss any concerns with your healthcare provider before the procedure.
During Knee Ligament Repair Surgery
How are knee ligament injuries treated?
Early medical treatment for knee ligament injury could be:
. Ice pack application (to reduce swelling that happens within hours of the injury)
. Compression (from an elastic bandage or brace)
. Pain relievers
A knee ligament tear can 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. People 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 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 an organ donor (allograft).
There may be other reasons for your healthcare provider to recommend a knee ligament repair.
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During a knee ligament repair surgery
Knee ligament repair may be performed on an outpatient basis or rarely as part of your stay in a hospital. Procedures may vary depending on your condition and your healthcare provider’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 healthcare provider will discuss this with you in advance.
Generally, the process of knee ligament repair surgery is as follows:
. You will be asked to remove clothing and will be given a gown to wear.
. An intravenous (IV) line may be started in your arm or hand.
. You will be positioned on the operating table.
. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
. The skin over the surgical site will be cleansed with an antiseptic solution.
. The healthcare provider will make several small incisions in the knee area.
. The healthcare provider will perform the surgery using an arthroscope (a small tube-shaped instrument that is inserted into a joint). The healthcare provider 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 an organ donor (allograft).
. The healthcare provider will drill small holes in the tibia and femur where the torn ligament was attached.
. The healthcare provider will thread the graft through the holes and attach it with surgical staples, screws, or other means. Bone eventually grows around the graft.
. The incision will be closed with stitches or surgical staples.
. A sterile bandage or dressing will be applied.
After Knee Ligament Repair Surgery
What happens after a knee ligament repair?
After the surgery you will be taken to the recovery room for observation. Your recovery process will vary depending on 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 healthcare provider 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 healthcare provider. Aspirin or certain other pain medicines may increase the chance of bleeding. Be sure to take only recommended medicines.
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 healthcare provider will arrange for an exercise program to help you regain muscle strength, stability, and range of motion.
Tell your healthcare provider if you have any of the following:
. Fever or chills
. Redness, swelling, bleeding, or other drainage from the incision site
. Increased pain around the incision site
. Numbness or tingling in the leg
. Calf swelling or tenderness
You may resume your normal diet unless your healthcare provider 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 healthcare provider tells you to. Other activity restrictions may apply. Full recovery from the surgery and rehabilitation may take several months.
Your healthcare provider may give you additional or alternate instructions after the procedure, depending on your particular situation.
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The bandage applied to your incisions may become moist or bloodstained; however this is normal and results from fluid placed in the joint during surgery. If your bandage becomes saturated with bright red blood, please call the office. Keep the bandages dry when bathing (“sponge bathing” is the simplest and easiest). Keep the bandages in place until you are seen in the office for your first postoperative visit, where you will receive instructions regarding further bandages and wraps, as well as showering or bathing.
For the first few days after surgery, you will want to limit your activities and rest your leg. Keep your leg elevated, with a pillow under your calf, and use the cold therapy device/ice packs to minimize swelling and pain. Use the CPM (continuous motion machine) for at least 2-3 hours a session, three times daily (more if you like.) Be sure to spend at least 6 hours out of each 24-hour day with your knee fully extended in the brace (this is easiest to do while sleeping).
When applying the straight leg brace, be sure to have your knee as straight as possible. When standing up or walking, use the crutches provided and have the straight leg brace applied to your leg. With the brace supporting your knee, you may bear as much weight on your foot as tolerated (unless instructed otherwise). There may be a sensation of splashing of fluid within your joint, but this is normal and should not cause concern.
. Pain control
You will find that your knee is swollen and uncomfortable for the first few days after surgery. To reduce this, use the cold therapy device/ice packs and elevate the joint as instructed. You have also been provided with medication for pain relief. Use it as instructed and take it with food to avoid stomach upset. If the medication provided is inadequate, or if you are about to run out, please call the office during daily office hours.
During your post-operative recovery, please keep track of how much pain medication you have remaining to ensure that you have sufficient medication for any upcoming weekends or holidays, as prescriptions are difficult to renew on weekends. You may also take ibuprofen as directed, which can be obtained over the counter.
If you develop a fever of 101 degrees or greater, if the pain you feel is much greater than expected, or if you develop severe redness or swelling, please call the office. Some calf and ankle/foot swelling occurs in all cases, but it can become severe. If you develop a reaction to the pain medication provided, stop taking it and call the office. Avoid direct sunlight on the incisions until the scars are no longer red. Remember that although the external incisions are small, you have had a major operative procedure within your knee joint.
Scientific research has shown that complete healing after knee ligament surgery takes 12-24 months. A very specific and thorough rehabilitation plan has been developed to guide you in your post-operative exercise and activities. You will begin this rehabilitation program after your postoperative visit. The plan may be modified, if necessary, based upon your individual rate of healing and recovery.
ACL home exercise guide for post-op recovery
If you’ve recently had ACL surgery, exercises are an important part of your recovery, in addition to a physical therapy program. Follow our home exercise guide for 1-4 weeks after surgery. The goal of these exercises is to regain neuromuscular control of the quadricep, strengthen the hip and maintain ankle range of motion on the affected leg.