Do I need ACL surgery?

[treehugger]

Hi All,

This is my first post as I'm a bit confused about the advice I'm getting on the NHS.

On Jan 16th I was snowboarding and had a bit of a run in with a tree which I couldn't avoid. Basically , I hit a branch of the tree with the side of my left knee, stopping it pretty quickly, but unfortunately the rest of me kept going. There was a sickening crack from both the branch and my knee ( I hope most of it was the branch!), and my knee was folded backwards and towards my right leg.

To cut a long story short, the diagnosis from the doctor in the resort (who obviously sees loads of knee injuries each year) and from my sister in law ( a GP) were a torn MCL and an ACL which had totally detached from the tibia, taking a piece of bone with it where it attaches. There was serious swelling immediately, requiring the joint to be drained and the nurse to faint! When I got back to the UK I had more X rays and an MRI which confirmed the original diagnosis. I don't know if the meniscus was damaged too.


Its now six weeks since the accident and I have just started to walk without crutches for a short distance, but can't lock my knee totally straight as I get a sharp pain behind my knee cap and it feels as if the shard of bone is getting in the way. The consultant I saw last week has recommended I don't have surgery,saying that I will be fine without an ACL as long as I keep my quads strong and do plenty of physio. This doesn't make make sense to me - what about the piece of bone floating around?! I know that surgery is often not recommended if you are over a certain age or quite sedentary, but I am 29, a keen mountainbiker, snowboarder and skier, with a generally active lifestyle - shouldn't I be having more than physio?

Anyone had similar advice?

[axomatic]

Firstly, bad luck on the damaging your knee, I'm a snowboarder so I know it's more common for skiers to injure ACL. I had my ACL repaired in Oct 05 after 6 months of going to physio & GP and not being given correct diagnosis. I was told to try and build quad & calf strength but it didn't work knee kept giving out on me and it was painful eveytime it happend. Eventually insisted on seeing a knee specalist and he correctly diagnosed problem in 10 minutes and then I had surgery. I'm very surpised the consultant didn't recomend surgery, was he a knee specialist ? I think that when your are able to start doing some sports activites again and you find your knee gives out on you, you will then understand that to get back to full fitness having surgery is the only option. It also depends on what sports you play, football, rubgy, squash & skiing would be a big problem with no ACL. If you look at the cruciate section of the forum you'll see an almost unanimous view that if your ACL is gone then the best thing to do is get it fixed. It could take a long time on the NHS due to waitin lists and going private will cost xc2xa34000-5000. Getting a good knee surgeon is important. The operation takes about 1 hour and you maybe in hospital for 1/2 days. Then a couple of weeks with crutches and approx 3/4 weeks off work. Then the hard part starts - the physio, it is boring to start, Range of motion stuff first then basic strenght building and progressing to more dynamic exercises i.e. shuttle runs etc. To return fully to sports will take 6-12 months depending on how dedicated you are to the recovery programme. Hope that helps, these forums are very good for advice and encouragement when you have a set-back. It's easy to loose focus and get depressed and certain stages of the recovery which can seem slow at times. Good luck in whatever you decided to do. One final thing if your not happy about the consultants view get a second opinion.

[CurtC]

Hey Treehugger,

Sorry I can't offer any advice on your healthcare ?s as I am in the US, but I think Axomatic made some excellent points about surgery:
-Getting a good knee surgeon is important
-depends on what sports you play but also what daily work/activity your lifestyle requires
-I also think that rehabing after surgery is just as important ( or more!) than the surgery...a lax effort in your rehab will ruin a good surgery

I tore my ACL ~1990 and just had it repaired 1 yr ago. I lived for 10+ years without one and was reasonably active using a knee brace for any sports. But, eventually my knee instabilty worsened despite my efforts to keep up my Quad/Hamstrg strength. I think "waiting" eventually caused more damage to my knee, and at the time of surgery I not only had a "missing" ACl but tears and chronic wear to both my medial and lateral meniscus! The cartilage damage is what I am worried about now....because an experienced surgeon with today's technology can do a good job repairing you ligament. It is the cartilage that, longterm, will continue to breakdown in a unstable knee and cause you problems down the road. Reconstructing, transplanting, or replacing cartliage in the knee and restoring cartilage function has not been successful.

I think not having an ACL all those years has contributed to the damage in my cartilage...and I wish I had surgery done earlier.

Good Luck!

CurtC

[harry78]

Hi all,

Some really good points there for you to take on board- depending totally upon the decisions you are prepared to make. On a another note though, if the real reason for your OS as you've mentioned is that you are in fact ok or could be ok without ACLR keeping your hamstrings and quadriceps strong then this is one route. The second route is you try and strengthen these muscle groups to no avail and as axomatic says the knee will 'give out' leaving you in agony and immobile once again. The third option is to elect to have ACL reconstruction and I would recommend this highly (even on nhs) because the risks are then outweighed by benefits in the medium and long term health of the knee. You are or will lose muscle mass and certain people can cope without an ACL but if you have damaged the mcl too, then the latter is the option if it was me anyway and did.
The first two though would be tricky and I have also been led to believe that losing the ACL in particular can lead to loss of control in the knee and indeed the whole leg because of the damage to and loss of mechanoreceptors. You probably have good anterior and posterior displacements even without an ACL, but it may be that it gives out unexpectedly in the future and risk damaging other precious structures within and out of the knee joint.

I hope this helps, Harry

[harmer]

Sorry about your injury. Tore my right knee ACl in 2003 and being stubborn did nothing about it but build up the muscles. This worked for a while (i play footy) but after about four months of training and matches it happened again, and to compound it i damged the cartilage badly as a siude effect. had the op in 2004 and having another one next week on the the other knee (thats another story!).

For me, and this is just my unprofessional opinion, i really don't think you'll ever be able to confidently enjoy your sport until you get an ACl reconstruction. I can't believe what your first consultant said. The others are spot on - get a second opinion.

As far as the NHS is concerned, i had an absolute nightmare with waiting for my first op, due to the complete inadeqaucies of the administrative side of the NHS. Waited 12months or more and ended up having it done at a private hospital but paid for by the NHS.

My advice would be to constantly harrass your GP into refering you for treatment asap. There are more options open to them and the nHS take more notice of GP referals. Ask him to refer you to your Primary Care Trust and also ask about new NHS schemes to cut waiting lists. (I think there is a new thing called 'Choose and Book'). You have the added bonus of already having your MRI results.

I am being treated next week - 6 weeks after my GP referred me. Not bad.

Good luck and get the second opinion!

[treehugger]

Thanks so much for all your advice guys, it's great to hear from others who have done similar horrible things and your various experiences. Most of all, you have all agreed with, and backed up my thoughts.

I think the consultant's main feeling was that the 6-12 months of post op rehab would not be worth it, although I have told him (twice ) how active I am and how I am happy to do the right thing for the long term. His reply is that 'there are plenty of rugby players out there who do fine without an acl' , but the idea of my knee going again just doesn't bear thinking about, I certainly would never want to risk skiing without an op. As a few of you also mentioned, I would hate to cause further damage to the meniscus or cartilage - in fact I feel like I would quite like them to have a look at the state of it while they are operating anyway!

I also felt that although my initial care, both in the resort and back in A&E in the UK, were excellent, especially getting an MRI so quickly; I wasn't so happy with the 5 minute general orthopeadic clinic consultation. On my first visit he didn't even examine my knee! So, I went to see my GP yesterday, and am getting a referral for a second opinion at another hospital.

I'll let you know how it goes...

[hopalongcasualty]

Yipee, it is the same old song and dance from the doctors everywhere.

Based on the rotational injury you described, it sounds like you have the unhappy triad ACL, MCL and Medial meniscus damage.

I really dispise the doctors who tell you that you can live without ligaments. Yes you can. But Doc you can live without a penis too and do you want to do that? I bet his answer would be NO.

If you were a couch potato with a sedantary lifestyle then don't do anything.

You are active and young, you want to continue doing "stupid" things (I do too) and you should not have to become a dismal human just because that doctor is oppinionated and probably quite envious of your lifestyle.

Keep looking for a KNEE SPECIALIST, I am in the States and am not too familiar with NHS, I am a fan of the concept because there are far too many citizens in the US who do not get ANY medical care because they are either unemployed or underemployed.

Once you are patched up and have gotten through physio, I would reccomend getting "FUNCTIONAL" knee braces with patella cup options for you to use when you go out and do your "STUPID" things . Custom fit is the best, I really like CTi's products, I have used several different mfg prods and have found CTi's stuff works best for me. Once I have finished my physio I will get my OS to give me a script for a new pair of CTi2 Hockey Braces. I will have to pay for them out of my own pocket but it is well worth it to me.

If you are looking for an off-the shelf alternative CTi EDGE with optional patella cup are good too. I have one of these that I was using on the right leg while skating but had not gotten one for the "good" left leg.

Also there are the Asterisk Cell braces, these have had good reviews from snowboarders and Motocross Riders. I currently am using a pair of these while I am getting the muscle mass back up. They are very adjustable, which is good for changing muscle mass during rehab.

In Summary:
1. don't give up - in my oppinion it is better to have ligaments
2. once you are fixed, brace yourself for fun. Being a lump in the snow sucks.

Best wishes,

Hopalongcasualty

[hopalongcasualty]

Just another thought, 2 of the 4 major ligaments are gone, you intend on hitting the slopes and bike trails again.
If your knee were to fully dislocate (femur/tibia) you run a substantial risk of irreversable nerve and/or vascular damage to the lower leg.
This could lead to paralysis or amputation of the lower leg.

Trust me I did the research and it scarred me too.

[treehugger]

Hi all,

It seems from everthing I've read and heard from people with similar injuries that surgery is my only option for a detached ACL. All those I know who have had it done are fine, but I am a little scared having read alot of the rehab stories on this site. Some great info though, as I feel I have been pretty kept in the dark so far by the NHS - you have to wonder if they are just trying to save money!

It sounds like axomatic, harmer and curtc have all been in a similar position - although I don't intend to do any sports other than some very sedate cycling for a good while yet, I am worried about causing further damage. How long can one wait before having surgery or does it not matter as long as you lay off the sports?

I have to say my knee feels pretty stable at the moment and I am finally walking without crutches - no pain when weightbearing and only a slight limp as I can't get my knee locked totally straight (I'm sure that bit of bone is in the way!)

At my last appt with the orthopaedic consultant he said that my MCL had pretty much healed and was stable, which seems about right. My leg was very floppy from side to side when it first happened but now seems OK. Wouldn't it be great if the ACL was that easy! I forgot to add that when I asked about the piece of bone floating about on the end of my detached ACL he said it would 'heal down and probably help provide some stability' (!?)

Anyway, first session of PT tomorrow morning we'll see what happens. Still waiting for a referral for a second opinion...

[Audice]

Hi treehugger ~ I'm one more victim of the unhappy triad knee, the result of coming off my horse & landing wrong. But I'm past the age where my ruptured ACL will be reconstructed. With a tear in my medial meniscus & an abnormal signal in the lateral, as well as a now healed MCL tear, I have only the option of dealing with the meniscus if it becomes problematic or having TKR. I'm being VERY careful not to do further damage to the knee.

If this injury had happened to me when I was your age, I'd certainly have ACLR done so as not to be constantly preoccupied with protecting my knee. I don't do anything less now than I did pre-injury, but it's annoying to have to think all the time about whether an action will result in my knee buckling or not.

Like you, I feel my knee at the moment is stabile & strong. But you know that a wrong move & it'll buckle. I was never on crutches but do wear a brace for any activity where I think it'll help matters. An OS friend, not the doc I'm seeing, saw me wearing the brace one day & not only approved it (Townsend Premier) but told me in no uncertain terms to "wear it." Wishing you well whatever decision you come to...Ellie

[celinenj03]

I look at it this way, I'd rather get it fixed and have all my pain and suffering at once rather than over the next 20 plus years and always worrying about my knee. It's only been 2 months for me and I'm already sick of talking and thinking about my knee. I'm going to bite the bullet and get it fixed. I know too many people who have fixed theirs and are doing great. I'm not going to be the one sitting on the sidelines of life if I can help it. So it's painful okay and it's a physical insult as some have said and I know the first month is going to be pretty awful, but it won't last forever. A torn acl and knee instability that goes uncorrected however, does last forever.

[Heather_M.]

In addition to reading the cruciate ligament information on the Kneeguru page (go to the main page and select from menu down the left side for great stuff on all kinds of knee issues), here is a link to my surgeon's web page. This link leads to a great article that is VERY easy to understand and goes over your options with a torn ACL, rehab, and recovery. Also, some FAQ's that you might find helpful:

http://www.steadman-hawkins.com/acl/overview.asp

Here's another one, with some info that is more technical. It also has details on other ligaments around the knee: http://www.kneehippain.com/patient/i_ligament.html

Finally, here is a board dedicated just to ACL injuries, with thousands of posts from folks just like you, wondering if they should have surgery. http://www.factotem.org/cgi-bin/kneebbs.pl

As for what you should do...well, given your age and activity level, it's pretty clear what the recommendations would be if money weren't an issue for your health care authority (i.e. if there were no national health care or HMO system making rules and deciding how patients should be treated, rather than doctors). I haven't had an ACL recon or anything, though we thought for a few months that I might have torn every ligament in my knee after being knocked down by a big oaf of a dog. But it seems pretty straight-forward to me: you were born with an ACL. Not having one can lead to pretty significant problems--that meniscus can be a pesky little piece of gristle (see the Steadman Hawkins link). And finally--this is something I know very well--it really sucks to wonder every time you step off a curb whether or not your knee is going to buckle under you and drop you to the ground. That fact alone would have me looking for a new doctor! Now maybe the doctor was recommending a 'wait and see' approach...though it didn't sound like it from what you said. It does make sense to do physical therapy to restore ROM and build strength, but I'd definitely get a second opinion from a doctor who fully understands your desire to remain active. Just my thinking, everyone has a different take on things like this.

Heather

[patpalloon]

Hi Treehugger,

I'm in a similar position to you on the NHS. I ruptured my left ACL in Sept 05. I'm a bit older (37) but still want to ski and do karate. I had the investigation done on the NHS (xrays, MRI and arthroscopy) but I'm going to have the recon done privately. I haven't got any health insurance, so I will have to pay myself. It's around xc2xa34500. The private hospital do a credit card - which gives you 6 months interest-free credit, so you can pay it off in instalments.

Go to www.drfoster.co.uk to find a consultant for ACLR in your area. Good luck.

Robin

[hopalongcasualty]

Think of it this way, in the future...

You are away on holiday and are going to cross the street to go to a shop or the beach. Will your knee keep you from sucessfully crossing the street or enjoying the beach?

While I was waiting for my graft, I had 3 business trips to the Carribean and could not venture more than 10 minutes on the beach before the pain was too bad. I also was not too keen on trying to cross the busy streets there either.

Just a thought... You can live without it... just a quality of life thing...

[treehugger]

Well, here's an update for you. I didn't have surgery. I continued with the physio.I could walk properly, although running hurt. I did a lot of mountian biking including a week in Croatia which involved hiking whilst carrying my bike, and although my legs were very weak, my knee held out fine.

Then last week my knee began to give out on me, normally when walking downstairs. One day it happened about six times, each time was a searing pain in the back of my knee like a trapped nerve, and my knee felt 'out of place', then it would go back into position and I could suddenly walk fine. Its happening less know , but my miraculous recovery its seems was too good to be true. So I'd better start saving up for that op!