Indications: Ruptured ACL
Patients are seen in this specific clinic approximately 2-3 weeks prior to surgery. Here they under a thorough assessment by both medical and nursing staff. This includes simple blood and urine tests as well as the taking of swabs which identify patients carrying certain bacteria including MRSA. Mr Hartwright sees patients at this point in order to explain the nature of the surgery and possible risks, identify any possible problems, obtain the patient’s consent to surgery and, of course, to answer any outstanding questions the patient may have.
Patients normally receive either a spinal (a needle into the spinal area causing numbness below the waist), or more commonly, general anaesthetic. There are potential risks with either technique and patients are encouraged to discuss any issues they may have with the Anaesthetist pre-operatively.
If a patient is thought to have any anaesthetic risk factors which may cause problems during, or after surgery, they are seen in pre-assessment clinic or given an appointment to see an Anaesthetist well before the day of surgery.
Whilst under anaesthetic, a thorough examination of the knee is performed. This is more thorough than can be achieved in the Out Patient Clinic. A tourniquet is applied and the leg exsanguinated.
Mr Hartwright reconstructs the ACL using the tendons taken from the hamstring muscles (Gracilis and Semi-Tendinosis). These tendons are removed via a small vertical incision over the front of the tibia (anteromedial incision). The tendons are prepared to create a 4-stranded graft.
Having prepared the graft, Mr Hartwright performs an arthroscopy. Using the arthroscope to direct a drill, he creates two tunnels through which the graft can be placed (one in the femur and one in the tibia).
The new ligament is then pulled into position through the tunnels and held at either end. Mr Hartwright usually uses an endobutton for the femoral fixation and an interference screw for the tibial fixation. However, the method of fixation may vary depending upon the patient and operative findings.
The average hospital stay is 1 day but this depends upon how quickly the patient recovers and rehabilitates.
Mr Hartwright encourages patients to start mobilizing as soon as comfort allows. This is done under the supervision of either the physiotherapists or nursing staff. Most patients start to walk on the day of surgery. Prior to discharge, patients are taught how to walk safely with crutches and climb a small flight of stairs. They are normally expected to achieve knee flexion of at least 90° (a right angle) before they are discharged.
Patients are provided with instructions as to the exercises that they should perform once discharged. It is vital that they do these exercises in order to optimize the results of surgery.
Mr Hartwright uses subcuticular sutures (placed under the skin) to close the incisions. These are trimmed at 10-14 days post-operatively. This is normally performed in the Out Patients Clinic (OPC).
Patients are discharged with compression stockings which are worn in order to prevent blood clots (Deep Vein Thrombses – DVT). They are instructed to wear these for 6 weeks.
< 2 weeks post-operatively:
Patients are encouraged to regain their full range of movement.
2 – 6 weeks post-operatively:
The main goal of rehabilitation is strengthening of the Quadriceps and Hamstring muscles. This is done through focused exercises of those muscle groups initially under the supervision of the physiotherapists but later these can be performed by the patient themselves. Patients are also given Proprioception (joint position sense) exercises; these are usually in the form of balancing exercises.
Patients are allowed to drive at 6 weeks post-operatively so long as they feel safe to drive (and are able to perform emergency manoeuvres).
6 – 12 weeks post-operatively:
More intensive exercises are commenced which can include cycling, gentle (straight line) jogging and swimming. These should only be performed after confirmation with your physiotherapist.
An ACL reconstruction can be damaged at any stage post-operatively, particularly with twisting injuries. It is at it’s most susceptible at approximately 12 weeks post-operatively. Patients should, therefore, be more careful with their knee around this time and should avoid pivoting/twisting for approximately 6 months.
3 – 6 months post-operatively:
At this stage specific exercises and drills will be started depending upon the patient and the sport to which they wish to return.
6 – 9 months post-operatively:
Depending upon the progress with the rehabilitation programme and their level of confidence, most patients can return to sport at this point.
Pre-operatively: Patients are pre-assessed so as to identify patients who are at greater risk of infection and measures are taken to decrease these risks e.g. Identifying and treating those patients who are MRSA carriers or who have urinary tract or other infections.
Patients are advised to take care of their skin pre-operatively; any cuts or scratches may allow bacteria to enter a patient’s system and consequently increase the risk of infection.
All instruments are sterilised to strict guidelines.
Joint replacement surgery is performed in specially designed theatres (with air filters and laminar flow) so as to decrease the risk of airborne infection.
The surgical site is prepared using antibacterial solution with the aim of preventing the entry of bacteria from the patient’s own skin.
All theatre staff directly involved in the procedure thoroughly wash their hands and wear sterile gowns and gloves such that no unsterile object comes into contact with the patient.
The surgical site is covered with a dressing so as to avoid infection from direct contact.
The rate of infection in patients undergoing joint replacement surgery is generally quoted as 1%. Link to RHCH infection rates.
Mr Hartwright’s rate of infection for joint replacement surgery is under 0.3%
Patients are encouraged to inform either the nursing and medical staff if they are experiencing pain. There are many analgesic agents at our disposal and there is no longer any need for patients to suffer in discomfort.
The rate of dislocation varies but is generally quoted as occurring in 1-4% of patients undergoing joint replacement surgery.
None of Mr Hartwright’s patients have suffered with a dislocation of their hip replacement.
Usually, any difference in leg length is not noticed by the patient but if it is noticeable (normally a discrepancy of ?2cm) then a heal raise can be placed in the other shoe to offset this inequality.
There are many other potential risks but the above probably represent the most important and certainly most asked about.