Surgery

Anterior Cruciate Ligament Surgery in Barcelona

Description

The anterior cruciate ligament or ACL is one of the four major ligaments of the knee and is fundamental to maintaining stability. Injury to the anterior cruciate ligament is one of the most common knee injuries. It usually needs surgery to rebuild it and to be able to restore normal joint function.

About half of the injuries occur in combination with injuries to the menisci, cartilage or other ligaments. In addition to providing stability to the knee, the ACL protects the meniscus and the cartilage. Therefore, it is common for ACL injuries that are left untreated to lead to injury of these structures. In turn, this will lead to the accelerated and early development of osteoarthritis.

Surgery

Anterior cruciate ligament surgery requires a thorough knowledge of the anatomy of its insertions as well as of the other ligaments and structures of the knee.

During his career as an anatomist and further development as a surgeon, Dr. Gelber has gained extensive knowledge in this field. It gives him a unique expertise when assessing injuries and reconstructing them as closely as possible to their prior natural state. The precise location of the tunnels is the most important aspect of ACL surgery. It is so much so that placement only millimeters off their optimum position is the main cause of ACL reconstruction failure.

In this context, ACL surgery has evolved dramatically in recent years. Not long ago and even in many places still today, the ligament is reconstructed with a central upright graft. This has led to continued rotational instability, which is most disabling and harmful to the patient. It has been shown that the best way to reconstruct the ligament is by reproducing its previous anatomy as this best restores its proper function in comparison to these previous techniques. Dr. Gelber has been a pioneer in Spain in the introduction of this technique and its variants of selective or partial reconstruction of the ligament. There are multiple scientific studies that Dr. Gelber has contributed to in this field of surgery. Although the ligament is functionally divided into two bundles, it has been demonstrated that it is not necessary to individually reconstruct each one in the complete tear. Different is the situation of partial ACL tears in which only one of the bundles is damaged. In these cases, treatment requires precision and experience as it is vitally important that the healthy bundle remains intact without injury during surgery while the damaged bundle is being reconstructed.

Anterior cruciate ligament surgery requires a thorough knowledge of the anatomy of its insertions as well as of the other ligaments and structures of the knee.

Alternatives

Hamstring tendons

Already in the operating room, Dr. Gelber uses different types of grafts for the reconstruction of the ligament, being in the vast majority of cases obtained from the patient himself. An alternative is the use of the hamstring tendons, which allow their extraction through a small 2 cm incision on the inside of the knee.

This results in less post-operative pain and better cosmetic results, as well as unbeatable clinical and sporting results.

Quadriceps tendon

Another tendon frequently used by Dr. Gelber is the quadriceps tendon. This alternative is most commonly indicated in revision surgery for re-ruptured ACL grafts.

Anterolateral reinforcement technique

Another field where Dr. Gelber is a world leader is in the so-called anterolateral knee reinforcement technique. It has been widely shown that in patients with more functional demands, such as athletes and those under 25 years of age, strengthening the anterolateral area of the knee with an anterolateral tenodesis or anterolateral ligament reconstruction decreases more than 3 times the possibility that the reconstructed ACL will break This is because of the supporting or collaborating effect that this anterolateral technique has with the ACL. Currently, Dr. Gelber performs this combination in 70-80% of ACL reconstructions.

Lateral Extraarticular Tenodesis

Antero Lateral Ligament reconstruction

Other tendons

Another option is the patellar tendon, but due to its possible consequence of pain in postures such as squatting, it is an alternative that is not currently used as a first choice except in selected cases. Finally, tendons from tissue banks are a valid alternative, although due to their higher rate of breakage in very athletic people and the fact that their healing requires more time, they are left as an alternative in the case of multiple ligament injuries or in very old patients low functional demand. In short, each has its advantages and disadvantages, and the most appropriate one is used in each case. The philosophy of Dr. Gelber is to adapt himself to each specific case and not offer the same treatment for people who may have completely different conditions.

Care

Before the surgery

Diagnostic tests

Dr. Gelber evaluates the knee using clinical tests, x-rays, and MRI to determine if the ACL is in fact injured. All this will help to determine if the ACL is intact, or if it has a partial injury or a complete injury. For diagnostic and therapeutic accuracy between different degrees of injury, precision and experience are required.

After surgery

The day after surgery and before leaving for home, the patient receives all the necessary information relative to postoperative care. The patient also leaves the hospital with an appointment for within 10 days or so to have the wound checked

Rehabilitation

The rehabilitation process is considered key to the reconstruction of the anterior cruciate ligament. It is imperative that the patient well understands the process to recover 100% of knee function. One of the most common complications after surgery of the anterior cruciate ligament is the loss of mobility, especially extension. This leads to limping, quadriceps muscle weakness and pain in the knee region. Many studies have shown that the worst time to perform the ACL surgery is when it is done with a swollen, painful and stiff knee. Therefore, this risk is minimized if surgery is delayed until the period of acute inflammation has passed, the inflammation has subsided a lot, complete or almost complete mobility is recovered and one can walk in an almost normal manner.

General Phases

PHASE Ia (0-2 weeks)

Aims to eliminate the effusion, pain and to initiate muscle activation.

Using crutches with complete discharge (non-weightbearing) of the operated leg
Isometric quadriceps exercises (leg raises)
Knee extension exercises until it is exactly equal to the healthy knee
Beginning of knee mobility progressively. Ideally with the use of continuous passive mobilization (Kinetek)
Maintaining the operated limb in full extension with an immobilizer during moments of rest or the first nights when sleeping.

PHASE Ib (2-4 weeks)

Aims to eliminate the effusion, to achieve full extension and restore muscle control of the leg.

Initial use of two crutches with partial weightbearing of the operated leg until full support, as tolerated
In the case of an associated cartilage surgery, it must be in a non-weightbearing condition 6 weeks
Isometric quadriceps exercises (leg raises)
Knee extension exercises until it is exactly equal to the healthy knee
Increase flexion to at least 90º. In the case of associated meniscal suturing or replacement, it should not exceed 100º until week 6.
No hamstring exercises or open chain exercises (Those where the foot is free, without contact).

PHASE II (From week 5 until the objectives of the phase are achieved)

Aims to normalize walking, have mobility without pain and be able to stand on the operated leg without Crutches

Achieve full flexion but avoid forced flexion
Isometric quadriceps and closed chain exercises (Those where the foot is supported with contact) up to 70° flexion
Hamstring exercises if your ACL has been reconstructed with OTHER tendons (not hamstring)
Balancing and proprioception exercises
Muscle stretches
No open chain exercises

PHASE III (From Phase II goals achievement until weeks 12-16)

the objective is to have control without pain with light and low impact exercise.

PHASE IV (from Phase III objectives achievement until week 24-40)

The aim is to have good neuromuscular control in specific low impact sports exercises

PHASE V: Return to any sports activity

Although there is the feeling that the knee is in optimal form many weeks before reaching this stage, the reconstructed ligament goes through a period of remodeling that even needs up to 2 years to complete. In any case, with the exception of cases of athletes who require an early return to their sports activity, it is advisable to avoid contact and pivoting activity until 8-10 months after surgery in cases where the sport is more casual type of.

Summary Rehabilitation Protocol

FOR YOUR PHYSICAL THERAPIST

Rehabilitation protocol for recovery

WITHOUT PHYSICOTHERAPIST

Frequently Asked Questions (FAQs)

When is anterior cruciate ligament (ACL) surgery necessary?

ACL surgery is usually required when there is a tear in the anterior cruciate ligament, compromising knee stability. This condition often results from a sports injury or trauma directly affecting the ligament tissue. When a partial or complete ACL tear occurs, activities involving sudden movements—such as running, jumping, or pivoting—can become difficult or impossible due to instability.

In many cases, if the tear is severe, surgery is the best treatment option to prevent future bone issues and improve knee mobility. Early diagnosis and treatment are crucial to prevent additional damage, such as meniscus tears or knee osteoarthritis. Once surgery is performed, the goal is to restore knee movement and joint function through a new ligament, using appropriate surgical techniques and following a structured post-operative rehabilitation program.

What pre-surgical tests are needed?

Before undergoing ACL surgery, a detailed medical evaluation is required to confirm the diagnosis. This includes imaging tests, such as magnetic resonance imaging (MRI), which allows doctors to assess the condition of the ligament and surrounding tissues. This diagnostic tool can also help detect additional injuries, such as meniscus tears, that may require treatment during surgery.

Additionally, general medical tests are necessary to ensure the patient is in optimal condition for general anesthesia and surgery. The doctor will review the patient’s medical history and any pre-existing conditions that could affect the procedure or recovery. Taking these factors into account is essential to ensure a successful surgery and an efficient recovery process.

How is the surgery performed?

ACL reconstruction surgery is typically performed using a minimally invasive procedure called arthroscopy. During the operation, a small camera-equipped device is used to visualize the inside of the knee, allowing the surgeon to make the necessary incisions to insert a tissue graft that will replace the torn ligament. This graft can be taken from the patient’s own body or from a donor.

The new ligament is secured in place using specialized screws or anchors to ensure proper functionality. In complex cases, additional repairs may be performed if other structures, such as the meniscus, are also injured. The procedure generally takes between one and two hours, depending on the complexity of the case, and is performed under general anesthesia to ensure patient comfort.

What surgical techniques are available for ACL reconstruction in Barcelona?

There are several surgical techniques for ACL reconstruction, with the most common being autograft and allograft procedures. The autograft technique involves using a tissue graft from the patient’s own body, typically taken from the patellar tendon or hamstring tendons. This method has the advantage of eliminating the risk of rejection and adapting well to the patient’s body, promoting a faster recovery.

On the other hand, an allograft involves using tissue from a donor, which is an option for patients who cannot provide their own tissue. While this technique is also effective, it may require closer monitoring due to potential complications. In some cases, a combination of these techniques may be used to tailor the surgery to the patient’s specific needs and ligament condition.

How long does the surgery take?

The duration of ACL surgery varies depending on factors such as the complexity of the procedure, the techniques used, and the patient’s medical condition. Generally, the surgery takes between one and two hours, including the preparation of the surgical area, ligament reconstruction, and graft placement. Specialized surgeons work with precision to minimize potential complications and achieve the best possible outcome.

Although the surgery itself is relatively short, the complete preparation and recovery process can take several months. After the procedure, it is essential to follow a structured rehabilitation program to ensure the new ligament and knee regain the necessary movement and stability for normal physical activities.

How long does recovery take after ACL surgery?

Recovery time after ACL surgery varies depending on the type of procedure performed, the patient’s age, and their overall health. Generally, patients can start walking with assistance shortly after surgery, but a structured physical therapy program is necessary to regain full movement and strength. Most patients can return to high-intensity physical activities within six to nine months, depending on their progress.

During the initial months, the knee requires special care and activity restrictions to prevent complications. Following medical recommendations is crucial, as returning to physical activities too soon can increase the risk of reinjury. Additionally, physical therapy plays a key role in strengthening the new ligament and preventing long-term issues, such as knee osteoarthritis.

Is the recovery process painful?

The recovery process after ACL surgery can involve discomfort and pain, especially in the first few days following the procedure. However, pain is generally manageable with prescribed medications and should gradually decrease as recovery progresses. It is common for the knee to be swollen and sensitive, so following medical instructions is essential for managing these symptoms.

As the body adapts to the new ligament and regains mobility, pain usually subsides. Physical therapy plays a crucial role in this phase by reducing stiffness and improving knee movement, ultimately helping to minimize overall discomfort during recovery.

What post-surgical care should I follow?

After ACL surgery, it is essential to follow specific post-surgical care guidelines to ensure a proper recovery. In the first few days, keeping the knee elevated and applying ice is recommended to reduce swelling. Additionally, following the doctor’s instructions regarding physical therapy exercises is vital for gradually strengthening the new ligament and restoring knee mobility.

It is important to avoid high-impact physical activities or sudden movements that could compromise knee stability during the early stages of recovery. Regular follow-up visits with the surgeon are also necessary to monitor for potential complications, such as infections or graft issues. With proper management and patience, post-operative care will help restore knee function.

When can I start walking after the surgery?

The ability to walk after ACL surgery depends on several factors, including the surgical technique used and how the body responds to the procedure. In most cases, patients can begin walking with support immediately after surgery, but it is essential to do so gradually and under the surgeon’s guidance. Physical therapy will also be crucial in strengthening the knee and helping the patient regain natural walking ability.

Most patients can walk without crutches or a cane within the first few weeks. However, it is important to avoid activities that place excessive strain on the ligament until the knee has fully healed. This approach helps prevent complications and ensures a more efficient recovery process.

Does ACL surgery guarantee full recovery?

ACL surgery has a high success rate and can allow patients to regain knee movement and stability, but full recovery is not guaranteed in every case. Several factors can influence the outcome, including the severity of the ligament tear, the surgical technique used, pre-existing medical conditions, and patient adherence to rehabilitation protocols.

While many patients successfully return to physical activities and their usual activity levels, there is always a risk of complications such as infections, stiffness, or damage to the new ligament. Early diagnosis, appropriate treatment, and strict adherence to medical and physical therapy recommendations are essential to maximizing the chances of a successful recovery.