Date: 11/7/02
Author: Marty "McFly" Head, Waterski Boats Dallas, and Dr. Kerry Donegan

Related Items:
The ACL Experience - Part I - Injury and MRI
The ACL Experience - Part II - MRI Results and Surgery Prep
The ACL Experience - Part IV - Physical Therapy
The ACL Experience - Part V - Knee Brace and Last Doc Visit
The ACL Experience - Part VI - Guess Who's Back Wakeboarding

Since I was in no frame of mind to take notes during the surgery, the following is a procedure summary of what happened in the operating room delivered to me by Dr. Donegan.

Torn ACL just prior to replacement

The anterior cruciate ligament is a stabilizing "rope" located centrally in the knee. It provides stability for cutting, turning, twisting and jumping motions. An athlete attempting to return to sports involved with these demands has a difficult time without the knee giving way. To surgically address the problem requires an ACL reconstruction. This means making a new rope (ligament). Suturing the torn ligament ends is ineffective.

The new ligament is made from a strip of tendon (a leader, which attaches muscle to bone). I prefer a strip of patellar tendon. The patellar tendon courses from the kneecap to the tibia (lower leg bone). A strip of patellar tendon with a small section of bone on both sides of the tendon (from the patella and tibia) makes a nice new graft (ligament replacement).

Anterior cruciate ligament reconstruction starts with knee arthroscopy. Through two small incisions, a small caliber tube with a camera lens is inserted into the knee. Saline solution is pumped into the knee to distend it, and another tube is placed into the knee to allow fluid to escape. Small instruments can access the knee through this tube. Arthroscopy allows visualizing and working inside the knee by small incisions. The knee is toured by arthroscopy and damage assessed. Often meniscus cartilage (the knee's padding) damage or articular cartilage (bone coating) damage must be addressed.

Guide ropes used once the new ACL path is cleared

ACL reconstruction involves "harvesting" the patellar tendon graft through a two to three inch incision on the front of the knee. Scalpels, scissors, a small saw, and small chisels are used to dissect the patellar tendon strip with a small bone fragment on both sides free. Sutures are placed on both ends through the bone plugs.

Using a special guide, a guide wire is placed through the tibia. The guide wire enters the inside of the knee joint where the ACL normally attaches to the tibia. A cannulated reamer is drilled over the guide wire to

A drill is used to tunnel into the tibia and femur.

make a tunnel in the tibia. This is repeated similarly in the femur to make a tunnel in the femur. The patellar tendon graft is then fed into the femur and tibial tunnels. The bone plugs on the ends of the patellar tendon graft end up in the femur and tibial tunnels. The patellar tendon strip ends up in the middle of the knee joint.

Screws are placed between the patellar tendon bone plugs and the tunnel walls in the femur and tibia to secure the graft. Absorbable screws are currently popular. The bone plugs on the graft ends heal to the surrounding bone tunnel wall just like in fracture healing.

Surgical closure involves filling in the bone defects on the patella and tibia with bone from bone tunnel drilling. Tissue layers are sutured and a sterile dressing placed.

The next thing I remember, which seemed like seconds after I was knocked out, was just barely opening my eyes and then getting sick. A nurse was standing next to me in the recovery room that was at the

The new ACL

ready in case this happened. I was told before that some people do get sick from the anesthesia and I figured I would be one of them since I have a weak stomach. However, this is why a patient is placed in the recovery room. The nurse immediately injected some anti-nausea medicine into my IV.

I felt extremely groggy and weak. All I wanted to do was just lie there and sleep, but I knew that I needed to try to come to my senses so I could get out of there and get home. I slowly regained consciousness and I remember feeling totally numb through my left leg. I was already bandaged up and had my knee brace on, but I was still under the covers in my gown. I also had a drain tube that went into my knee right on top of my kneecap. The tube went into a compressed bag that needed to be drained about 2 times a day. I was told that a home health care nurse would come to my house the next day to remove it.

The metal extracted from my knee, about the size of half of a sunflower seed shell.

Once my vitals came back to normal and I was pretty much awake, I was taken into a post-op room where my wife came in to greet me. She had talked to the doctor and he said that everything went according to plan. He had even gotten out the piece of metal that was stuck in my knee. The nurse left us so I could get dressed, and, once I was ready, the nurse came back and she and my wife helped me down into a wheel chair. I was wheeled directly out of the post-op room, down the hall way and out into the waiting room where my dad had the car parked just outside of the front door. I got in the back seat with my leg stretched out and then I was on the way home.

I really didn't feel anything in my leg. I was no longer nauseated and I actually felt pretty good. I was fully alert and could think straight. The only thing that was slow was my speech. I could think and knew what I wanted to say just fine, but getting the words out of my mouth was another story.

I got home about 30 minutes later and, once I got out of the car, I was able to walk on my crutches under my own power into my house. I got situated on the couch with my leg propped up, we placed an ice pack on the knee, and I was good to go. Just like I was told, I felt really good, basically like nothing had happened that day. Even though I did feel like eating again, I waited another hour.

I only ate light the rest of the day. I had soup and crackers, and, although I was hungry, I could not eat very much at a time. I took my pain medicine as instructed and about 30 minutes to an hour after I took each pill I would take about a 45-minute nap. I really couldn't do much the rest of the day because I was so run down. Even though I felt just fine, any little thing I did made me really tired. My knee was also locked at about 10 degrees in my brace, so I couldn't really bend it anyway.

I slept on the couch the first night and woke up early the next morning. I kept ice on it most of the night, just as I had done since I got home from having the procedure done. I ate a light breakfast and just rested comfortably that morning. I waited on the home health care nurse to call to let me know when she would be there to remove my drain tube.

She finally called around noon and told me to go ahead and take two pain pills, and that she would be there in an hour. I was excited for her to get there because I wanted to unwrap my knee to get a look at it. However, I also was nervous because I really didn't want to feel any pain since I hadn't felt any as of yet.

The nurse arrived at 1:00 the day after surgery and she had me sign a few forms before she did any work. Once the paperwork was out of the way, she began to unwrap my knee. Obviously, the knee brace was the first to come off. Wrapped tightly around my knee was an ace bandage, and under that were squares of cotton, which covered my stitches. Then there were strips of wound tape that covered each incision point.

The tube was placed directly on the top center of where the kneecap would normally be. However, my knee was so swollen, the tube was not hitting the cap. She began to pull on the tube slowly before she removed the wound strips and I kept waiting to feel something, but I never did. My knee was still totally numb and I never felt a thing as close to four inches of drain tube was pulled out. She then removed the strips of tape off of my incisions.

The nurse was very careful to clean up the incision areas. I had 2 stitches on each side of the knee, which is where each camera was put in. I then had a four-inch vertical cut that runs just to one side of the lower area of the kneecap. However, the stitches for this incision were internal and would not have to be removed.

Once the wounds were clean, she placed new wound strips over the incision points with fresh cotton to keep it padded. Then we put the ace bandage back on along with the knee brace, and topped it off with an ice pack. She had completed service in about 20 minutes and she was on her way.

At this point, I decided to get out of the house, so I went up to the dealership (Waterski Boats Dallas) to see what all was going on at work. I could maneuver around just fine on crutches and still had not felt any pain. However, after an hour of being out and about, I was wiped out and ready to return home to the couch.

That evening, I began to look at my list of exercises, which I needed to start. Since the surgery is so hard on the quadriceps muscle, I knew that I needed to begin work on that as soon as possible. My quad was already extremely weak from the surgery, and I knew it would just get worse unless I started to try to fire it sometime soon. I tried to fire the quad and keep it flexed for five seconds, and then I would relax it. My goal was to do this 30 times in a row before giving out. I just sat on the couch with my leg stretched out and propped up and would flex the quad without moving the leg. The exercise seemed so simple, but it was so difficult because it was like my brain had totally forgotten how to move that muscle. Basically, I had to re-teach my brain how to control that muscle all over again.

The goal of the weekend was to do a straight leg raise before I went to Physical Therapy on Monday. I wanted to try to get the quad strong enough so that I could do one on my own. Straight leg raises were on my list of exercises to do over the three-day period between the surgery and my first therapy session. I was to either lie on the couch, or sit at the end of a chair and lift my left leg straight up, pulling the heel off of the surface, without bending my knee. It was another exercise that seemed so simple, but it was so hard to accomplish. It turns out it was something that I was not strong enough to do just yet.

As each day passed over the weekend, I got up and about more and more on my own. I did not attempt to drive yet, but I could get in and out of the car on my own and I could move around just fine on my crutches. Dr. Donegan told me that I would walk off of the crutches within a week and I was really looking forward to that. I was anxious to get to Physical Therapy as well because I wanted to really start working the knee and getting my range of motion and muscle tone back as soon as possible.

Physical Therapy was another experience in itself. I still had not felt any pain in my knee, but I figured I was about to since I would be working it more and more starting on a regular, supervised basis.

Check out more on Marty's rehab coming soon...

Part II - MRI Results and Surgery Prep

Part IV - Physical Therapy

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