Failed ACL Surgery

ACL injuries occur frequently among athletes and non-athletes. It is estimated that there are over 100,000 ACL reconstruction surgeries each year in the United States. In most cases, there is between an 80-90% success rate for ACL surgeries. However, in a few rare cases, ACL reconstructions fail.

Pain after an ACL surgery requires careful evaluation, and may result from ACL graft failure. In general, a failed ACL surgery can occur for multiple reasons, and treatment to correct this failure is often complex and technically challenging for the surgeon. As an orthopedic knee surgeon, Dr. Lubowitz specializes in revision of a failed ACL surgery.

Following ACL reconstruction, and after appropriate time and healing has passed, patients who still complain of instability, knee pain, limited range of motion, and knee stiffness are often the ones who experience a failed reconstruction. If the failure occurred within 3-6 months following the initial reconstruction, the failure was either due to surgical technique, graft failure, or a rehabilitation program that was too aggressive. Failures that occur later (6 or more months following surgery), are usually due to a newly developed injury.

If it is believed that a failed ACL reconstruction is causing the pain and instability, Dr. Lubowitz will carefully identify this problem through a thorough exam, full patient history, physical exam, x-rays and an MRI will be conducted. The goal will be to determine the cause of failure, and to plan a surgery revision technique that will lower the risk of a second failure.

Every situation and patient is different. Dr. Lubowitz will devise a tailored plan and approach for each patient. Treatment for a failed ACL may require staged procedures, and could involve removing old fixation devices, and possibly bone grafting to correct widened or poorly positioned bone tunnels or sockets. In some cases, a realignment may be necessary so that the knee is in alignment with the rest of the lower body. A revision surgery will most likely use an allograft, and frequently requires repair or reconstruction of other structures including other loose ligaments.

Following revision surgery, a 6 to 12 month rehabilitation process will ensue. Full weight bearing is sometimes delayed, and a return to certain activities and sports may be longer than after the initial surgery.

Revised ACL reconstruction surgery is something that takes precise planning, and careful evaluation. It is critical to understand the exact cause of the ACL failure for success in the future. The revision process requires a strong partnership between the patient and Dr. Lubowitz, so that every step taken is a step towards a successful recovery.

Treatment Options

ACL Revision for Failed ACL Surgery

For more information on failed ACL surgery, please request a consultation with orthopedic knee specialist, Dr. Lubowitz, by clicking the link below.

ACL Reconstruction Surgery

ACL reconstruction surgery has come a long way in recent years. Using advanced, minimally invasive, arthroscopic techniques, patients are able to quickly recover and return to the same level of sports performance or physical activity prior to their injury. If Dr. Lubowitz determines that surgery is the recommended course of action, a tailored surgical treatment plan will be provided for each patient. This treatment plan will detail pre-operative preparation along with providing information about the surgery. Once arthroscopic knee surgery is completed a full rehabilitation plan will be set in place. Rehabilitation is essential for a successful recovery.

Surgery Versus Conservative Treatment

The ACL does not heal naturally due to poor blood supply and general anatomy of the knee. Depending on the type of ACL injury, surgery is not always required. Surgery will depend on the patient’s age, activity level before surgery, and ongoing athletic and fitness goals post-operatively. Most patients under the age of 40 will be recommended to have ACL reconstruction surgery so that the risk of a meniscus tear and arthritis can be reduced. Instability is also a critical symptom following an ACL injury. Instability is troublesome for patients, and for patients with unstable knees, surgery is recommended. Patients who are older and lead a more sedentary lifestyle may not require surgical treatment. In such cases, patients will be offered physical therapy and encouraged to wear a knee brace.

Arthroscopic Treatment

In most cases, the ACL will be treated arthroscopically using the least invasive, “all-inside” or “no incision” techniques. Arthroscopic knee surgery involves the use of a fiber optic camera (smaller than a pen), which is put into the joint through a keyhole sized arthroscopic portals. The arthroscopic camera allows Dr. Lubowitz to gain a complete visual of the inside of the knee joint as the image is displayed and viewed on a high definition (HD) television. While inside the knee joint, additional instruments will be inserted through another portal so that Dr. Lubowitz can feel and assess the knee structures. This will allow for a better diagnosis as well as proper steps to repair, reconstruct, or remove damaged tissue.

ACL Reconstruction Grafts

In knees that have ligament damage and need ACL reconstruction surgery, which is the case for the vast majority of knee reconstructions, Dr. Lubowitz will use a certain type of graft during the process. A replacement graft is precisely positioned in the joint at the site of the former ACL, and then fixed to the thigh and lower leg bones with adjustable TightRope buttons, or in some cases bioabsorbable screws. There are currently several options for replacement grafts. Regardless of the graft material chosen, the most important aspect is that the ligament graft is placed and secured precisely. Accurate graft placement is essential for a good result and securing graft placement permits early, more aggressive rehabilitation after surgery.

Choices for the type of replacement graft include:

  • Autograft: This graft uses tissue from the patient. The tissue will most likely come from the quadriceps tendon, hamstring tendon, or the patella tendon. Autografts offer great success rates because they result in a strong graft, secure fixation, and excellent biological in-growth. Since the graft comes from the patient, there is little risk of disease transmission. A disadvantage is donor site morbidity, but using an all-inside technique, Dr. Lubowitz is able to reconstruct the ACL using minimal native tissue. Following a strict post-operative rehabilitation program, patients are typically able to resume full activities with few complications.
  • Allografts: In some cases, Dr. Lubowitz will recommend using an allograft. This is donor tissue taken from tissue banks. Similar to an autograft, these also yield very good success rates and are strong and healthy to use. Because an additional surgery site is not needed on the patient (as is the case using an autograft), the surgery time and recovery time tend to be quicker, with less pain, and a faster recovery time. Therefore, an allograft is frequently selected for patients greater than 40 years of age. Although, there is a risk of infectious disease, donor tissue is obtained only from a reliable tissue bank. The tissue is rigorously screened and treated to prevent the spread of infectious disease. The risk of contracting infectious disease from an allograft is very small (less than one in eight million). Rejection of the graft is also possible, but this is a very rare occurrence since the tissue is not living material. Rather, the graft is a scaffold, which allows in-growth and remodeling using the patients own cells and own DNA.
  • Synthetic grafts: This graft is available for use in certain situations, but most are experimental and do not work as well as allografts and autografts. Synthetic ACL grafts cannot be recommended at this time.

After ACL Reconstruction Surgery

Arthroscopic knee surgery for an ACL tear typically lasts one or two hours. After the operation, patients will be taken to the recovery room to be monitored to make sure all vital signs are stable, and that the anesthesia is wearing off properly. Patients will go home the same day, and be given specific instructions to follow at home. Exercises will begin the day after surgery, and formal physical therapy will be introduced in less than 7 days. It is critical that patients follow the post-operative protocol that Dr. Lubowitz specifies. Rehabilitation becomes as important as the surgery itself.

For more information on ACL reconstruction surgery, please request a consultation with orthopedic knee specialist, Dr. Lubowitz, by clicking the link below. 

ACL Diagnosis

Whether from a sports collision or an accidental fall, an ACL injury is very common today. Initial ACL diagnosis will include the individual feeling a sudden pain and a giving way of the knee. Many patients report hearing a pop, followed by swelling, tenderness, and looseness (laxity) in the joint.

A clinical ACL diagnosis will include an assessment of range of motion, limb alignment, muscle strength, neurovascular status, and a thorough comparison with the uninjured knee. During the initial consultation, Dr. Lubowitz will evaluate the type of ACL injury, will obtain a full report on how the injury occurred, determine if the injury is new or pre-existing, determine if the injury is combined with other injury, and discuss the details of the treatment options. He will perform a physical examination that will involve several injury specific tests. These tests will help him to accurately diagnose the ligamentous and patellofemoral instabilities that exist within the knee. These tests may include:

Pivot-Shift Test

The Pivot-shift test checks for anterior instability. With the patient supine the knee will be extended; the ACL-deficient knee will demonstrate anterior tibial subluxation. As the patient’s knee is flexed to 30° to 40°, while valgus force is applied, the anterolateral tibial subluxation will abruptly reduce.

Anterior Drawer Test

The Anterior Drawer Test is used to check for anterior instability. With the patient supine and the knee flexed to 90°, an anterior force is applied to the proximal tibia. Tibial anterior translation and quality of the endpoint are evaluated.

Lachman Test

The Lachman Test is also used to check for anterior instability. With the patient supine and the knee flexed to 30°, an anterior force is applied to the proximal tibia. Tibial anterior translation and quality of the endpoint are evaluated.

Magnetic Resonance Imaging (MRI)

During each of these tests, the knee will feel unstable and loose, and the patient may experience muscle guarding in anticipation of movement. While Dr. Lubowitz can often diagnose the ACL injury through a series of these tests during the clinical evaluation, he will always order a set of x-rays to make sure that there are no broken bones in the knee or other damage. If Dr. Lubowitz suspects that there is damage to the ligaments, menisci, joint surfaces (cartilage), or bone, he will also want to obtain an MRI. Unfortunately, almost half of all ACL knee injuries involve the menisci, and an MRI is the best way to obtain a visual of how much damage has occurred. Based on all of these evaluations, Dr. Lubowitz will be able to provide an accurate ACL diagnosis.

For more information on ACL diagnosis, please request a consultation with orthopedic knee specialist, Dr. Lubowitz, by clicking the link below. 

Types of ACL Injuries

There are several conditions that cause varying levels of anterior cruciate ligament (ACL) instability. These include: sprains, avulsion fractures, ACL deficiencies, and complex ligament injuries. More than half of all types of ACL injuries occur with associated damage to another part of the knee – most commonly, another ligament, articular cartilage (bone lining), or meniscus (cushion pad). Types of ACL injuries can be diagnosed by a thorough examination, X-rays, and magnetic resonance imaging (MRI).

ACL Sprains

A sprain occurs when the fibers or threads of the ligament are stretched, partially torn, or in severe cases, completely ruptured. ACL sprains are classified by a grade as follows:

Grade I ACL Sprain

Grade I sprains are considered the most mild of the different types of ACL injuries. While patients will experience symptoms, they can usually be treated without surgery. This type of ACL sprain occurs when the fibers of the ligament are stretched, but a tear does not exist. For the most part, the knee will remain stable. Symptoms of a Grade I sprain include tenderness, swelling, moderate knee pain, and some limit to mobility. A period of rest, along with anti-inflammatory medications, crutches, and ice can usually remedy this type of injury.

Grade II ACL Sprain

A Grade II sprain refers to an ACL injury where the fibers of the ligament are partially torn. This particular injury occurs occasionally, but in most cases the tears will be complete. The same symptoms apply as a Grade I sprain, however they tend to be more severe. The difference is in the instability, because some fibers of the ligament are actually torn, and the joint may feel unstable or as if it will give out during activity. In other cases, the joint will feel stable, so not all Grade II sprains will require surgery. Reconstruction of a partially torn ACL will depend on the patient’s age, activity level, and sports or fitness goals, and will primarily depend on the patient’s symptoms. In cases of instability, partial, or complete, ACL reconstruction is typically recommended.

Grade III ACL Sprain

Grade III sprains are the most common types of ACL injuries among athletes. This occurs when the fibers of the ligament are completely torn. This is often referred to as a rupture, meaning the ligament has completely torn apart into two sections. Symptoms of a Grade III sprain are frequently more severe. Swelling and tenderness may be immediate, knee pain can be severe, and stiffness may result. Rarely, a complete ACL tear can occur without pain, swelling, or stiffness Grade III sprains almost always leave the knee unstable. For this particular grade of injury, reconstructive surgery is usually recommended, once full extension is achieved and the swelling decreases.

ACL Avulsion Fracture

ACL avulsion fracture is more rare than an ACL sprain, and occurs when the ACL tears by breaking a piece of bone off from where the ligament attaches to the thigh or leg. In most cases, it’s the tibia (leg bone) that is affected—meaning, the ACL rips by breaking (fracturing) a piece of bone from where it attaches to the shinbone. This is usually the result of excessive overuse and muscular contraction during sports. Direct trauma through a blunt force or hit can also cause this type of injury. ACL avulsion fractures are more common in children than in adults, but can occur in adults, and are quite common in skiers.

ACL Deficient Knee

Knees that do not have an anterior cruciate ligament, are in most cases unstable, and instability results in unwanted, ongoing symptoms for patients. The most prominent symptom is knee buckling, which will be felt during running and cutting activities, as well as walking down stairs, and sometimes during other everyday activities. In other cases, there is a sensation that the knee will buckle if the patient is not careful and attentive. While patients can live with ACL deficiency by decreasing activity, this can lead to meniscus tearing, cartilage damage, and eventually, the onset and progression of osteoarthritis. These additional knee injuries are due to buckling, the sensation of buckling, or even as a result of micro-instability. Therefore, surgery is usually recommended for younger patients, active patients, or patients who live in areas or have occupations which require climbing or walking on uneven ground.

Complex and Multi-Ligament Knee Injuries

Sometimes, in conjunction with an ACL injury, other damage may exist within the knee. The ACL may become injured along with meniscus damage (which occurs in the vast majority of cases), or with damage to cartilage. Damage may also occur to the ACL plus another ligament. Multi-ligament damage usually occurs when a traumatic event is severe. If it is suspected that the ACL is injured along with another knee structure, a thorough exam, followed by an X-ray and an MRI is required. When multiple knee ligament injuries occur, sometimes, a knee dislocation or fracture can also be present. In order to correct the overlapping injuries, Dr. Lubowitz will need to perform a multi-ligament reconstruction surgery to repair damaged ligaments, as well as use a graft to replace ligaments and tendons that cannot be saved.

For more information on types of ACL injuries, please request a consultation with orthopedic knee specialist, Dr. Lubowitz, by clicking the link below. 

ACL Injuries In Patients Over 40

As people age, many decrease their level of sport or activity, and nonsurgical treatment is always an option for patients with ACL injury who are willing to stop cutting and pivoting sports, or work and activities requiring walking on unstable ground or terrain. Knee injuries create physical restrictions for many patients over the age of 40 that remain very active. Different types of ACL injuries can occur in both athletes and non-athletes. If the individual wishes to maintain a high level of activity, reconstructive surgery may be the best option. In clinical studies, including research published by Dr. Lubowitz, it has been concluded that surgical management is the optimal treatment strategy for an ACL rupture in patients ages 40 years or older.

Dr. Lubowitz has published research on treatment options: Operative Versus Nonoperative Treatment of Anterior Cruciate Ligament Rupture in Patients Aged 40 Years or Older.

For more information on ACL injuries in patients over 40, please request a consultation with orthopedic knee specialist, Dr. Lubowitz, by clicking the link below. 

ACL Injuries in Children

ACL injuries in children are becoming more prevalent today. While the exact number of ACL injuries among the pediatric population is hard to identify, there is strong evidence to support a substancial increase. Researchers believe the main cause is due to children becoming more involved in competitive sports at a young age. The high intensity training, partnered with little rest, increases the risk of injury. Children experience ACL injury in a manner similar to adults, typically as a result of a sudden event, rotation, or irregular movement.

ACL reconstructive surgery is often the recommended treatment for ACL injuries in children. Advanced surgical techniques are required during repair to lower the risk of an abnormality or deformity during future bone growth. ACL injuries in children continue to be a concern for pediatric orthopedic doctors as youth sports continue to grow more competitive.

For more information on ACL injuries in children, please request a consultation with orthopedic knee specialist, Dr. Lubowitz, by clicking the link below. 

ACL Injuries in Women

ACL injury in women is four times more likely to happen than it is for men. ACL injuries in women, especially female athletes, is becoming an epidemic. Sports that produce the most ACL injuries in women are basketball, volleyball, skiing, trail running, gymnastics, and soccer. The increase of ACL injuries in females is becoming a challenge for the sports medicine community as we work to protect their female athletes.

While there is not an exact reason why ACL injuries afflict women more than men; there is a clear anatomical difference between the knees of a man and a woman. Researchers believe this structural difference is the main cause for higher incidence of ACL injuries in women. Several theories include:

  • A wider pelvis in women: This results in a wider quadriceps angle. This is the angle at which the femur (upper leg bone) meets the tibia (lower leg bone). It is thought that this increased angle places more stress on a woman’s knee joint, which makes it less stable than a man’s knee joint.
  • A smaller intercondylar notch: This is the area in the knee that lies between the two ends of the thighbone. This particular space is larger and wider in men than it is in women, and may result in the ACL rubbing against the bone, and tearing.
  • Biomechanical alignment: As girls enter puberty and adolescence, the size and shape of their hips naturally change. This affects the alignment from the hips all the way down the lower extremities. Many variables can become risk factors for injury, including the ligaments that support these structures.
  • Muscle strength and muscle fatigue: When fatigue sets in, components within the knee joint, and surrounding structures must compensate for that weakness. This leads to tension and force of movement that is inevitably transferred to the ligaments, which puts them at risk for ligament injury.

While it is still not clear what exactly causes women to suffer more ACL injuries then men, the sports medicine community is becoming more aware, and are implementing ACL injury prevention programs for female athlete injuries. These programs combine strengthening, stretching, and proper knee support to help decrease the risks of future ACL injuries.

For more information on ACL injuries in women, please request a consultation with orthopedic knee specialist, Dr. Lubowitz, by clicking the link below. 

How ACL Injuries Occur

There has been a substantial increase in ACL injuries in recent years. An increase in fitness and competitive sports has strongly corollated to the rise in ACL tears. There are a number of ways an individual can injure their ACL. How ACL injuries occur continues to be researched by the sports medicine community. The majority of ACL knee injuries are the result of low-velocity, noncontact movements, with a rotational component. Contact sports such as football and wrestling can also lead to an ACL injury along with injuring the ligament secondary to twisting, valgus stress, or knee hyperextension.

Below, we have broken down the most common ACL injuries:

ACL Injuries in Sports

Participation in sports is the most common cause of ACL knee injuries. Specifically, ACL sports injuries occur during twisting, cutting, or pivoting moves. The sports involving these movements the most are snow skiing, soccer, basketball, football, volleyball, and tennis. In these types of sports the foot is often planted with the knee bent, and a sudden change in direction stresses the ligament. An example of this is the fast, sharp cuts that soccer players, or a football player make.

Snow skiers are particularly susceptible to ACL injuries due to the nature of strains placed on the joint. These forces include balancing the legs during movement, making a solid landing during a jump, rotating the body during turns, and higher forces such as skiing over moguls or downhill speed racing. ACL knee injuries in snow skiers can affect professional skiers, all the way down to the recreational novice skier.

In addition to the sudden movements experienced in these types of activities, contact sports, as well as direct hits to the knee, also put the ACL at risk for injury. Direct blows to the kneecap can force certain structures within the joint to move forwards or backward, resulting in injury. An ACL knee injury can also result from a severe hyperextension of the knee joint.

Treatment

Treatment options for athletes will depend on their preoperative activity level, and if they wish to continue at that level post-surgery. Patients at a Level 1 or Level 2 are those that partake in jumping, hard cutting, pivoting, fast running, or side-to-side sports; we recommend a Level 1 and 2 to to get an ACL reconstructive surgery.

For more information on how ACL injuries occur, please request a consultation with orthopedic knee specialist, Dr. Lubowitz, by clicking the link below. 

Anatomy of the Knee

The anatomy of the knee is made up of three bones:

  • The femur (thighbone)
  • The tibia (shinbone)
    KneePic
  • The patella (kneecap)

In addition to these bones, the knee is supported and controlled by several muscles and ligaments that help create normal motion and protect the knee from damage.

While the medial collateral ligament (MCL) and lateral collateral ligament (LCL) help to stabilize the knee from side-to-side motions, the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) function together to support the knee during normal activities and sports by protecting it from front-to-back movement. All four of these ligaments work together in harmony to ensure that proper unloading takes places within the joint, and that the weight is evenly distributed throughout.

Another important component of the anatomy of the knee is the articular cartilage. This is a smooth lining that covers the end of the knee bones, and which acts as a shock absorber, allowing the knee to perform movements and motions. When the weight of the knee is evenly distributed, the articular cartilage is protected. In addition to cartilage, the knee also contains two very important structures known as the medial and the lateral menisci. The menisci reside on either side of the knee joint acting as shock absorbers.

For more information on the anatomy of the knee, please request a consultation with orthopedic knee specialist, Dr. Lubowitz, by clicking the below link. 

Focal Articular Cartilage Defect

Articular cartilage defect is a common knee injury. Cartilage is frequently injured, often resulting from sports related trauma or overuse. The articular cartilage has a limiting capacity to heal itself naturally, due to the anatomy of the knee. Articular cartilage damage can worsen over time if not properly managed. When the cartilage defect is localized to one specific area within the joint, then it is referred to as a focal articular cartilage defect. Innovative treatments exist for focal articular cartilage defects.

Symptoms and Diagnosis

Symptoms of focal articular cartilage defect include: pain, throbbing, swelling, tenderness, and limited mobility. In some cases, cartilage can become loose and float in the knee joint, causing patients to have catching or locking in the knee.

If Dr. Lubowitz decides that cartilage damage is the proper diagnosis, then a thorough history will be gathered, along with a physical examination and x-rays to check to for any fractures or other damage. If a focal articular cartilage defect is suspected, an MRI will be needed to asses the size, location, and extent of the damage. By using an MRI, the cartilage and surrounding soft tissue can be identified and assessed for proper treatment.

Treatment

Dr. Lubowitz will recommend treatment based on the severity of the diagnosis. For symptomatic focal cartilage articular defects, surgery may be beneficial and holds great promise. There are many articular cartilage repair and restoration procedures that may help symptoms including debridement, microfracture, cartilage transplantation, and osteochondral autograft, or allograft. Typically, Dr. Lubowitz will treat focal defects using an arthroscopic approach, but complex or large defects may require open surgery.

For more information on focal articular cartilage defect, please request a consultation with orthopedic knee specialist, Dr. Lubowitz, by clicking the below link.