An impatient’s guide to Knee Surgery – Anterior Cruciate Ligament (ACL) Reconstruction and Meniscus Tear

The story begins many years back, on a beautiful sunny morning in 1997. I was playing cricket in the inter division cricket tournament in my college. I had bowled my quota of overs and we had kept the opposition down to a modest score. Later while batting we were within reach of the target with 10 runs to get and 8 balls to go. 8 balls 10 runs wasn’t easy but I did think we could make it. I took strike, the bowler bowled a delivery that rose to about waist height. I swung the bat in what is known as a pull shot, hoping to get a boundary. My bat moved, my chest and waist rotated in an attempt to generate max power, but my legs did not move. I heard and felt a snap / pop in my left knee and I was down in excruciating pain. I could not even think of getting up, let alone running. After a few minutes of agony, I was helped off the field. We later lost the match.
Disclaimer – I am not a doctor. I am publishing this article a few days prior to the 3rd anniversary of my knee surgery. It is based on my notes and my experiences. However there is absolutely no assurance that any statement in this article is medically correct or up-to-date. The article cannot substitute the advice of a medical professional.

I wasn’t sure, but I dreaded that I had done the same thing that my sister had a few years back while playing badminton; I had torn the ACL ligament in my knee. The knee soon swelled up and I could barely manage to get back home.

Initial Treatment & Doctors

My first doctor was Dr K who ran an orthopedic hospital near my place. He wasn’t very convincing, did not give much of a diagnosis and suggested that we do an arthroscopy before he could comment. I had heard tales of this particular doctor making patients go through expensive & unnecessary procedures. For a second opinion, I went over to Dr. D, a nice man in his 50s. He asked me to have a few XRays taken, but apparently XRays don’t tell much when it comes to muscle tears. He asked me to take some medication for the swelling and then exercise my quadricep and hamstring muscles. He was reluctant to recommend any surgery and felt that I should first recover from the current injury, strengthen the knee and then see how it goes.

I exercised in right earnest for many months. I could barely walk the first few days but gradually I could again walk well, run and even play some sports occasionally. However every few months I would accidentally do something that would lead to my knee getting dislocated. I dislocated twice while attempting to play badminton and several times while getting down stairs & while walking on uneven terrain. In hindsight, it seems rather silly of me to try to play badminton with a bad knee, but I was in college then and I couldn’t resist accompanying friends to such games. I knew I was risking a dislocation but still went ahead.

update – I am told that ‘Subluxation’ is the correct word for what I am referring to and not ‘Dislocation’.

I had about 3 to 4 knee dislocations every year. The thing with dislocations is that while the first disloaction gives you excruciating pain, your body seems to adjust to that and the ones after that are very painful but not as bad as the first one. You also recover faster than the first time. I soon even got the knack of using my hands to manouver my knee into position, immediately after a dislocation.

However after one particularly painful incident, I again went to Mr D. He again asked me to continue my exercises for quadriceps and hamstrings, but this time he also asked me to visit Dr. J in Mumbai. A doctor now very famous as he is the often associated with the Indian cricket team.

Dr J was good at his job. He did a couple of simple knee tests. The Lachman Test in particular can make it very obvious to the patient that something is very wrong inside the knee. During the test, the part above the knee and below it seem to work independently of each other if you have a torn ACL. It’s quite a scary feeling. *Note that 10s of doctors & assistants have tried this test on my knee, and I have found that very few get it right. If the patient does not relax his/her muscles, the knee doesn’t respond and the doctor can be fooled into thinking that the ACL is ok.

Dr J said that no MRI or XRay was required and he was convinced that I had ACL Insufficiency that required an operation. Dr J had an athletic built and a smart & confident manner, making it easier to believe that he is a sports injury expert and is sure of his assessment. I was also impressed by his willingness to give a definite diagnosis, without any arthroscopy or MRI scan.

He added that if I did not want to go under the knife, I could keep exercising my quads and hams and stop all activities that test the knee. It’s beyond me why doctors insist on using confusing words like insufficiency, words that patients cannot make any sense of? I guess it’s similar to us software folk making it seem like developing a web page is a big deal. You stay important, your opinion is valued and the client pays good money willingly.

Having the second option of exercising my way out, made things difficult for me. No one wants to be operated on, so I hoped that I would be the lucky one to just exercise and get through. I did get through a few years, but how could a 18-20 year old not push the knee. I regularly ended up doing things that my knee disapproved of. So not only did I gradually lose confidence in the knee but I now regret having missed out on many activities in college just because I feared that my knee could not sustain them. Also with time, the ACL injury only gets worse. The exercises build up muscles that try to compensate for the ACL, however the ACL does not get better with time. It’s also easier to bounce back from a new ACL injury than an old one (in both the physical and mental sense). A failed ACL also increases your risk of arthritis as there’s friction caused by the knee not moving in it’s proper plane.

658px-Knee_diagram.svgSo if you had a knee accident where you felt a pop/snap, it is unlikely that you have just damaged your ACL but not torn it. As ligaments don’t heal by themselves, your choices are –
1) Exercise – Build up related muscles (quadricep and hamstring) so as to compensate for the torn / damaged ACL. Leg extensions and leg curling using weights will work out these muscles. But just these two exercises don’t suffice.
2) ACL reconstruction Remove a ligament from the hamstring (alternatives to the hamstring ligament exist) and replace the ACL with it.

For many years I was under the impression that I had damaged the ACL but not torn it and I could pull through. Stupid decision in retrospect! I thought that reconstruction wasn’t really necessary in my case. My sister who had to undergo the ACL reconstruction many years back used to dislocate her knee very frequently and so had no choice but to get it operated. As I only dislocated every 3-4 months, me and my family did not take my knee injury as seriously as we should have. We perhaps thought that only if you slip and fall every second day is your ACL torn, else it’s just damaged and will recover over time. Big mistake! How often you fall depends on how strong your quadriceps & hamstrings are and how capable they are at compensating for the ACL.

Based on what I have now experienced and read I now feel that if you are young and active, a surgery is your best bet. It is not only unlikely that you will regularly exercise your knee all your life but you also won’t be able to cut down on activities that test the knee. Although I believe I took good care of my knee, it is pretty much impossible for a youngster to not test the knee. If you are old and not very active, strengthening the muscles might take you through.

I did not go for an operation and sort of accepted the occasional dislocation. I exercised quite regularly and took the 3-4 dislocations an year as a part of life. This went on for many years.

In the meantime, after another rather painful dislocation, I was told by someone to consult Dr S. It’s funny how hope drives some patients to quacks promising miracle drugs while others like me to doctors whom you think will tell you things that you want to hear. Dr S was well known for not recommending surgery. He asked people to walk in swimming pools and recommended seemingly strange exercises. So I went to Dr. S hopeful of learning his magical exercises and sorting out my knee troubles for good.

If I remember correctly, Dr. S hardly touched my knee, let alone examine it. He looked at an old X-ray, did not provide any diagnosis but said that he will fix things. His assistant gave me a photocopied paper that had some exercise diagrams. She quickly told me what those exercises were, I was asked to pay a huge amount in cash (no receipt) and was whisked out in maybe 2 minutes or so. Even if the doctor hadn’t been around, I think the assistant could have managed things just as well. The procedure was simple

a) Note which part is affected b) Give corresponding exercise sheet c) Demonstrate exercise d) Collect big fat sum e) Bye Bye

I did follow the exercise routine for some time, but I wasn’t very committed as I did not think much of the doctor. So, many years after the cricket accident I still had a bad knee that dislocated at will. I am sure it would sound ridiculous to some readers that I wasted 10 years trying to pull through with a broken knee. Honestly, I agree. Things just happened that way.

They say that adversity can be a blessing in disguise. One evening in Jan 07 I was moving about in the kitchen when my knee again shifted and for the first time it did not release, it locked. Normally my knee dislocations felt something like ‘Khat-Khat’ and that too when I was pushing the knee. This time it shifted when I wasn’t doing anything abnormal and now it was locked. I tried to release the knee but I later learned that I should not have done that as I could have caused severe damage to the meniscus. It hurt bad and the knee swelled up. I was worried and mad at myself and all my doctors over the years.

I had recently noticed a new sports medicine clinic that had come up near my place. It was being run by a young Dr. B whose wife was a friend from my school days in Mumbai. It’s strange how life can get you to run into people you least expect. I had faint memories of being impressed on hearing that my friend was marrying a doctor currently in the UK for studies. Apart from getting some occasional info from common acquaintances I had completely lost touch with them. I restored the link and got an appointment with Dr B.

ACL Reconstruction and Meniscus Tear Surgery

Dr B examined my knee, asked me to get an MRI scan done. An MRI scan entails spending a long time in a noisy and annoying machine. Once the MRI reports were in, Dr B was convinced that I should get the knee operated. He felt that the knee had got worse with time and getting the ACL Reconstruction surgery done was the way to go. He did not feel that I could just keep exercising quads and hams and pull through. This was good in a way, as now the option that had held me back from surgery was eliminated. We decided on Dinanath Mangeshkar hospital in Pune as the place for the surgery.

Update – The MRI done usually before all ACL surgeries is essentially to delineate all the deficits within the knee as a prognostic indicator. So that the surgeon can tell you how much arthritis there is pre surgery & that will not recover. and associated collateral damage of meniscal tears.

Countdown to the operation

  1. Day minus 3 – I got my blood, urine and sugar tests done. The reports were normal.
  2. Day minus 1 – I was told to get admitted to the hospital the evening before the operation. As far as I can understand, this served no purpose. My operation was scheduled for 8.30 the next morning. I think it would have sufficed if I had got admitted a couple of hrs prior to the operation.
  3. Day 0 – My leg was shaved at about 7am. I was told to not eat or drink anything since the previous night. I believe this is meant to ensure that you do not throw up on the operation table. At about 8 am I was taken to the operation theater.

Operation Time
Prior to the operation I was asked to change into the ugliest clothes I have ever worn. I do not know why hospitals try so hard to make patients feel sick. Making patients wear drab and humiliating operation costumes that leave the patient pretty much naked makes no sense for a knee operation. I deeply regret that I did not protest and insist that I will not wear the gown or whatever it was. To add to it, the operation table was just 6 ft and so I wouldn’t fit in. My feet were sticking out, atleast till the time I was knocked out.

ACL Arthroscopic reconstruction - Image via Wikipedia

You have to make a few choices before the operation. You need to be take these seriously as for everyone besides you, this is just another operation.

What kind of Anesthesia

  • General Anesthesia will knock you out for a long time. The period when you come out of a GA is especially unpleasant. If you take a GA, the key thing is to not fight the GA. If it wants you to sleep, sleep. One of my worst memories is of the time when I was trying to come out of a GA for a minor nasal surgery I underwent a long time ago. I could hear and understand what was happening around me but I just couldn’t wake up. I am told I talked a lot of nonsense in this phase, which was funny for others but very unpleasant for me. Ask someone in your family to remind you to sleep and not fight the anesthesia.
  • For the knee operation I was to be given a spinal injection. The injection numbs you below the waist. The injection did not hurt much.
  • I was advised by family to opt for a sedative after being administered the spinal anesthesia so as to not feel the stress of the operation. I opted for this, which perhaps was not the right decision. I hate the feeling of being out of control. I could have tried staying awake and if I had felt stressed out by the operation I could have taken the sedative. However this sedative thing was nowhere as bad as a GA. This decision really depends on your personality than anything else.


Other decisions

  • Medical professionals by and large are very reluctant to provide any info or reasons. Unless you ask them why you should do X or Y, they will not tell you. For some patients “because the doctor says so” might work. Certainly not for me. If you have read Lance Armstrong’s book “It’s not about the bike” he talks at length about how you need to work with the doctors and not just wait and hope that the doctors will pull you through. My case was a 1000 times simpler than fighting cancer, but I do think the more aware you are, the easier and faster you would recover. Ignorance is also very irritating. Knowledge keeps that one big irritant away.
  • Ask a million questions and do not expect the doctors to volunteer information. Trust me, they will not, at least not in India.
  • Ensure that the intravenous (IV) is stuck on a shaved patch of skin. It will hurt when they remove the IV a few days later and a 100 hair along with it. I now better appreciate the pain that women go through when they wax their arms clean. Ouch!

The actual ACL Reconstruction surgery

ACL reconstruction is not an ACL repair. A repair implies that you can fix something that is broken. If an ACL is completely torn, it will not heal back together, even if the torn ends are sewn together. In actuality, the tendon almost always appears frayed when visualized after an ACL tear. What does work well, is to remove the torn ends of the ACL and replace the ligament with a different structure (a graft). To secure the graft into the position of the normal ACL, tunnels are made in the shin bone (tibia) and thigh bone (femur), and the graft is passed through these tunnels to reconstruct the ligament. (src about.com ). The graft can be from the hamstring tendon, patellar tendon or a donor/cadaver graft.

The operation lasted for a couple of hours and I was then wheeled out to a recovery room. Apart from the ACL tear I also had a meniscus tear, so I was told that a part of the meniscus was also removed. Immediately after the operation, my big problem wasn’t pain in the knee but a severe pain in the stomach. I soon realized that it was caused because my bladder was full. The reason wasn’t that I had not used the toilet before the operation but because I was given lots of fluids during the operation. The big problem was that as I still had no sensation below the waist, I could not relieve myself. It was very very painful. The doctors on duty at the time had no answers. Like with so many other embarassing things at the hospital, during the hours when I had no control over my bladder, I wet my bed even when I sneezeed / vomited. I couldn’t help it, I had no sensation below the waist. Although I hated the idea of wetting my bed, it did help with the pain.

Recovery

Day 1 was horrible. I knew of my sister’s agony after her ACL operation many years back but was hopeful that technology & medication would have improved since and the pain would not be too bad. I was very wrong. Also there was a medical goof up at this stage. Everytime I was given what was supposed to be a painkiller injection, I puked within 30 seconds. Apparently I was reacting to that particular drug and the drug failed to relieve pain. Strangely no one from the hospital staff thought of changing the injection. Only after I insisted was the injection changed the next day.

Stitches Just Below Knee - 1 week after operation

Night 1 was perhaps my worst night ever. I was up all night trying to find some position and posture where it wouldn’t pain, but to no avail. Along with my knee my back had also started hurting big time. It was agony that I will never forget. For some strange reason I remembered a line from renowned Marathi author P L Deshpande’s book, where the funny but wise character of the old Parsi ‘Peston Kaka‘ says that he believed that “God Is In Suffering Whatever Comes Your Way“. All night I kept telling my wife that I was getting a very close view of God through my suffering. My wife later told me that the night was a traumatic experience for her, as she couldn’t bear to watch me suffer. So if you are undergoing the operation, plan for about 18 hours of agony. Hopefully in your case the painkillers will perform better than in mine.

Things improved significantly on Day 2, I am not sure if it was the new painkiller that did it or the pain naturally subsided. On Day 3, I was allowed to use the walker to move about and I also started some light exercises. I was asked to spend a few more days in hospital. Apart from continuing with my exercises I didn’t do much during these days. I do not think much was achieved by me staying in hospital beyond day 2. Doctors perhaps want to play it super safe and so prefer to keep the patient in hospital until they are 100% sure. However I feel that if you are in good physical condition otherwise, you should talk to your doctor well before the operation on when exactly you will be set free from the hospital. Hospitals are not hotels, it’s better to get out asap.

I had 6 stitches just below the knee and one on each side of knee. Knee swelling is the first problem to be tackled. Although the hamstring seems very far from all the action, it does hurt a bit as that’s where the replacement ligament comes form. Bending the knee and getting it back to normal motion is what all the exercises are about. Exercising using a knee bending machines was much better than human assisted exercises my sister had gone through.

Knee Brace

The first brace that was put on immediately after the operation, stayed on for 3 weeks. This brace stopped me from bending my knee while walking. After about 2 weeks, my swelling had subsided but was not gone altogether. Initially I was not supposed to bear any weight on the knee but after 2 weeks, full weight bearing on the knee was now ok. The knee was now bending a little more than 90 degrees. BComplex tablets were the only medication I was now taking. I had to take pain killer tablets for a few days after the operation, but the pain had subsided since.

After 3 weeks I switched to Hinged Knee Support. I was looking forward to moving on to this brace as with it I was told that I could bend my knee while walking. But this new brace was a big disappointment. Neither could I walk comfortably nor did the brace feel like any support. I read on some websites, that these support braces have more of a psychological benefit than physical, as the brace keeps your brain alert and tuned into the knee’s movements. The first 2-3 days with the new brace were especially bad. Either my skin reacted badly to the neoprene material or because of the excessive sweating caused by the brace, I had a major rash and itch in the area covered by the brace. The itch was unlike any I remember. I repeatedly woke up in the night just to scratch my knee until it was all red and itched even worse. Ice packs and cold water were the remedies that worked best in tackling the itch. After 2 days of this, my doctor prescribed a medicine and I changed the cloth I used under the brace from a sock like material provided by the brace vendor to a more comfortable cotton. I was expecting to be back in action in one month’s time, but that didn’t happen. I could stand on my feet and walk around in the house but couldn’t venture out. The brace that was supposed to let me walk while protecting my knee didn’t seem to achieve much either.

Circle encloses a Titanium endobutton - Rectangle encloses a Bio Absorbable screw. Rectangle denotes the track of the screw. Source - JointAndBones.com

After 8 weeks I had started vigorous exercises that were meant to strengthen my hamstrings, quadriceps and other muscles that control the knee. Exercises using rubber bands (thera band) work well as you can apply pressure evenly and also control it yourself rather than rely on the physiotherapist.

Stairs were a problem area even before the operation and they continued to be even at this stage. For about 2 months, I was climbing up and down stairs using only my one good leg. Getting down stairs was especially tough, I am told that this happens because muscles find it easier to control the knee against gravity than with gravity. I distinctly remember standing on top of a flight of stairs and finding it difficult to believe that getting down a few small steps had become so very difficult.

After a couple of months, it was just regular strength training for the knee. Also I do not know how, but I was told that some other muscles get ‘wasted’ due to lack of use when my operated leg was not in action. So I had to build overall strength of the leg and also had to take up other exercises for core strengthening.

In conclusion

Although I had taken down notes before and after operation, I have been able to actually complete this article only a good three years after the operation. So how has my knee responded over 3 years? Am I glad I went for the operation? Yes, getting the knee operated I think was the right decision. My knee is now stable and it hasn’t dislocated in the 3 years since the operation. Am I back to full fitness, is the knee as good as new? Unfortunately no. Despite a lot of training, swimming & cycling, my knees still hurts at times. Actually the non operated knee hurts more often than the operated one. The doctor feels that it’s because I have been protecting the operated knee and overloading the other knee.

Have I resumed sports? No, except for controlled sports like cycling, swimming & jogging. The doctors say that weight training will get me best results on the knee, however I have found jogging, swimming & cycling are best for the mind, as they make me feel healthy & sporty and I feel like I have overcome the knee barrier. Just weight training does not instill that confidence.

Despite the operation it now looks like occasional knee pains will be a long term irritant for me, and I will have to keep strengthening the knee all my life. I have found that the best remedy to knee swelling / pains is to resume knee exercises. My hamstrings for the operated knee are still not as strong as the other knee. Also as a portion of meniscus was removed during the operation, the shock absorption capacity of the knee I am told has also reduced, I do not feel the difference.

If you are reading this to decide whether you should go for the operation. I would suggest that if you are below 45 and lead an active lifestyle, get operated, get it done with. Getting the ACL repair done early, can get you a near complete recovery & strength and and also save your meniscus.

Hope this article is of some use to someone somewhere struggling with an injured knee & damaged anterior cruciate ligament (ACL). In summary, I would say read up as much as possible, consult multiple doctors and then take your own decision.

Update – 24 July 2010
Thanks a lot for all the comments.
A quick update. I have been quite regular with the exercises. I have mostly used my home gym & therabands for knee exercises.
However my operated leg (left) continues to be much weaker than the right.  My doctor felt that a Vitamin B12 & D3 deficiency is hampering my recovery. My B12 and D3 figures were not satisfactory in a lab test. So took those supplements for a month and increased my exercises. I was also running about 3 kms every alternate day.
That’s when .. trouble struck, again…
A few days back while carrying my 1yr 9m old son & trying to squat to pick something from a low table, my operated knee went cruuunch. This was the 1st such event in over 3 yrs. It felt like the crunching sound you get when you twist your neck at odd angles. I did not fall or anything, but the knee hurt and went very weak.
20 days later, my knee still feels weak. I continue to exercise, but have stopped running. My doctor checked the knee and fortunately thinks that the ACL is ok. He however feels that I need to increase weight training and also continue with the supplements. A scary line he added was that for repairs done a long time after injury, full recovery might not happen.
My weak hamstring (from where the graft was removed) is the problem. Despite all kinds of exercise, the muscle just refuses to regain strength comparable to the other leg. The problem with the hamstring is also that it is a tough muscle to exercise. Unlike say muscles like calf muscles, which you can easily exercise anytime using your body weight for resistance. For hamstrings you need weights and/or machines.
Felt rather hopeless post this event and it seemed like the knee problem is going to be with me for life. But then hope gradually returned and I resumed exercise. 1) Because if I dont exercise, I would be in even bigger trouble. 2) Considering the kind of disabilities people get from accidents or no fault of their own, I guess, the torn ACL lot are much better off.
I hope all readers are having a better time with their recovery. Push Push Push with the exercises.
I am wondering if exercising as if you want to resume competitive sports, and maybe having a personal trainer would be a worthwhile investment.

Tips & Tricks

  1. Crutches are much easier to use than a walker. Even one crutch will suffice.
  2. If you wake up in the middle of the night with a hurting knee, in all probability you exercised subconsciously. Wearing the brace loosely fastened at night might help keep your knee in check.
  3. Turning on the side got me my first proper nights sleep after the operation. My left knee was operated so I could not turn to my right as then my left knee would hang loose. But turning to the left and keeping my right knee on a stack of pillows worked well. This may seem like a trivial thing to provide as a tip, but considering how much relief it brought me, it’s anything but trivial for me.
  4. First day is very very painful. I was unfortunately given a painkiller that my body rejected. If the painkiller isn’t working or you are reacting to it, ask if the injection can be changed right away. You are the only one who feels the pain, the doctors won’t volunteer much info or change of medications without you being proactive.
  5. Never rely on just your family or the doctors to do what is best for you. They do not feel the pain and only superficially understand your case. Make your voice heard if you are in any discomfort due to medications or facilities.
  6. “Depends on the patient’s response” is the most irritating answer that you will get regularly in response to queries to doctors. Ignore. Ask more Qs.
  7. Immediately after the operation, trying to stay calm & patient is the key. Shouting at family & friends will only make matters worse for everyone.
  8. When you try to walk in the first few days, don’t forget to fasten the brace really tight. It will hurt if your knee wobbles. Pulling your knee cap in while taking every step, will also help. If your knee bends / buckles / wobbles, it can hurt quite bad.
  9. Using the toilet on your own will be a difficult task in the first few days. A low seat will make matters worse.
    The way to do it is to bend your good knee and sit down on the toilet seat (your hands also need to take some weight). You can then extend your operated leg and rest the heel on a chair. Keep another support below the calf muscle. You should be able to manage.
  10. Pay close attention to what you eat. You definitely don’t want an upset stomach, constipation, etc.
  11. I have found the kitchen to be most demanding on the knee as you are constantly changing direction and making sudden movements.
  12. If you are a vegetarian, for calcium & B12 drink milk without adding any coffee, bournvita, etc. for flavouring. I disliked plain milk earlier but now happily gulp down a couple of glasses of milk every day.
  13. I would suggest that if you are undergoing the operation, you ask family and friends to not visit you in the first 2 days. Everybody who turns up at the hospital is wishing well for you but it’s difficult to wish well for anybody who stays in your room for longer than 5 minutes. An uncle of mine used to get a magazine and some goodie for me everyday and his was one of the very few visits I looked forward to while in hospital.

Resources

  1. ACL Tears
  2. How To Lessen Risks Of Knee ACL Injuries
  3. ACL Injuries – WebMD
  4. Should I opt for ACL surgery?
  5. Theraband Exercises For ACL Recovery

ACL Videos

  1. Anterior-Cruciate-Ligament
  2. Medial-Meniscus-Injury
  3. Acl Surgery