Anterior Cruciate Ligament (ACL) reconstruction 前十字韌帶重建

Dr. Adrian Leung > Anterior Cruciate Ligament (ACL) reconstruction 前十字韌帶重建

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Anterior Cruciate Ligament (ACL) reconstruction 前十字韌帶重建

Background 背景

When the Anterior Cruciate Ligament (ATFL) is torn, an injury commonly happened when one sprains his knee, the stability of the knee will be compromised.

While the muscle at the back of the knee can partially compensate the loss of the ACL, in front to back shear. There is no muscle which can be the check rein for axial rotation. And in conditions when the thigh muscle is in fatigue, or when the strain comes in quick such as stepping into a hole, then the instability will be obvious. It is estimated up to 40% of sprain knee injury will end up having additional structural damage, such as meniscal injury or osteochondral lesion. Repeated injury can mount to 80% in these cases.

Repeated injury to the knee not only causes pain and swelling, but also create additional and cumulative injury to the surrounding soft tissue and bone. When the femur and patella are under repeated shearing injury, osteochondral lesion might be resulted, and this lesion is a challenge. Therefore, in most cases, surgical intervention will be needed to lower the risk of having these secondary injuries.

Therefore, unless the patient is much sedentary and not doing any sports, or having high surgical risk, otherwise, Anterior Cruciate Ligament (ACL) should be reconstructed as soon as possible.

ACL can be reconstructed by minimal invasive technique, which is now standard procedure rather than open technique.

Reconstruction of the Anterior Cruciate Ligament (ACL) can be by means of harvesting hamstring or patella tendon as graft.

After reconstruction, a period of protection is required before the new ligament regains its strength.

The followings are additional surgical procedures, addressing different concomitant pathologies,

  1. Partial menisectomy
  2. Meniscal repair
  3. Chondroplasty
  4. Microfracture
  5. Loose body removal
  6. Posterolateral complex repair
  7. Medial Collateral Ligament repair
  8. Medial PatelloFemoral Ligament repair

當膝蓋扭傷導致前十字韌帶（ATFL）撕裂，膝關節會變得不穩定。

大腿後方的肌肉可以部分彌補ACL的功能，避免不正常的前後活動。但沒有肌肉可以制止膝關節內旋。而且，在大腿肌肉疲勞或事發突然肌肉反應不及，例如誤踏到路面的洞中，便會更感受到膝部不穩。據估計，多達40％前十字韌帶撕裂病例會伴有其他的結構損傷，例如半月板損傷或骨軟骨損傷。如不修復，80％會有再次的受傷。

膝關節反復受傷，不僅會導致疼痛和腫脹，還會對周圍的軟組織和骨骼造成額外的累積損傷。當膝關節反復受到剪力損傷時，可能會導致骨軟骨病變，而這種病變要處理好並不容易。

因此，在大多數情況下，除非患者少行走，不參加任何運動，或手術風險高，否則，醫生會建議重建前十字韌帶以降低這些繼發性損傷的風險。

通過微創技術重建前十字韌帶，已是標準程序。開大刀在過去十年已經十分罕見。

醫生會移植大腿後肌腱或髕骨肌腱來重建前十字韌帶（ACL）。

重建後，在新韌帶恢復強度之前需要一段時間保護，但絕少需要配戴支架。

以下是針對不同同時出現的傷患而附加的外科手術程序，

  • 半月板切除術
  • 半月板修復
  • 軟骨打磨
  • 微骨折
  • 碎片移除
  • 後外側修復
  • 內側副韌帶修復
  • 內側髕股韌帶修復

Indication 適應症

  • Anterior Cruciate Ligament (ACL) deficient knee 慢性前十字韌帶過鬆
  • Acute traumatic rupture of the Anterior Cruciate Ligament (ACL) 急性前十字韌帶撕裂

Preparation 預備

  • Pre-op workup 手術前身體檢查
  • Walking >10000 steps a day 堅持每天1萬步強化背及腿肌
  • Do more deep breath 多深呼吸
  • Continue usual medication on operative day 手術當天照常食藥
  • No food or drink for 6 hours 手術前6小時禁食及禁喝水
  • Admit to hospital 3 hours before surgery  手術前3小時到醫院
  • Inform your relative despite surgery takes less than 2 hours, you will return no earlier than 3 hours. 通知家人即使手術只需2小時，但回病房可能是3小時後

Risk 風險

While all medical and nursing professionals endeavor to provide best and safest practice, complications still would occur. General operative risks including heart attack, stroke, wound infection, wound hemorrhage, urinary tract infection, deep vein thrombosis, scar pain, unsightly scar, wound gapping and even failure to heal, etc, is possibly encountered.Nerve and vascular injury are rarely occurred risk but can be catastrophic with limb loss. There are occasions the hamstring tendons are not big enough and need to open up a new wound to harvest patellar tendon. Anatomical variants also carry more risk.Persistent instability is around 10%. Therefore, early protection and avoid enthusiastic stretching and weight bearing in early stage is important.儘管醫生和護士都會盡最大努力提供最佳和最安全的治療，但併發症仍會發生。 一般手術可能會遇到的風險，包括心臟病發作，中風，傷口感染，傷口出血，尿道感染，深層靜脈血栓形成，傷口疼痛，外觀不理想甚或傷口不癒等，這手術也不例外。神經及血管損傷是很少遇上，但可導致災難性截肢。 如大腿後肌腱不夠粗，可能需再開傷口取髕骨腱。先天結構異常也會有更高的風險。持續不穩大概為10%。所以早期保護及避免太早活動及受力尤其重要。

Budget Estimation 預算費用 (Hong Kong 香港)

CPT code and RVU is as follows
  • 29888, Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction., RVU 14.3
  • 29882, arthroscopy, knee, surgical; with meniscus repair (medial OR lateral), RVU 9.63
  • 29881 partial menisectomy, RVU 7.03
  • 29877 chondroplasty, RVU 8.3
  • 29879 Microfracture, RVU 8.99
CPT碼和RVU如下
  • 29888　關節鏡輔助的前十字韌帶重建，RVU 14.3
  • 29882　關節鏡半月板修復（內側或外側），RVU 9.63
  • 29881　半月板切除術，RVU 7.03
  • 29877　軟骨打磨，RVU 8.3
  • 29879　微骨折，RVU 8.99
Estimation based on general ward as in Aug-2020,
  • Surgeon fee $57,200 (ACL), $86,090 (reconstruction and meniscal repair)
  • Anaesthetist fee $19,066 (ACL), $28,696 (reconstruction and meniscal repair)
  • Ward round $1,200/day
  • Hospital charge $60,000 (ACL), $68,000 (reconstruction and meniscal repair)
Total $138,666 (ACL), $185,186 (reconstruction and meniscal repair) around
根據普通房於2020年8月進行的估算，
  • 外科醫生費$57,200 (前十字韌帶重建), $86,090 (前十字韌帶重建兼半月板修復)
  • 麻醉師費$19,066 (前十字韌帶重建), $28,696 (前十字韌帶重建兼半月板修復)
  • 巡房費$1,200
  • 醫院費$60,000 (前十字韌帶重建), $68,000 (前十字韌帶重建兼半月板修復)
  • 總計$ 138,666 (前十字韌帶重建), $185,186 (前十字韌帶重建兼半月板修復) 左右
hamstring graft
hamstring graft 大腿後肌鍵，預備轉移
quadruple hamstring graft
quadruple hamstring graft 對摺成四條肌腱

Reference figures from private hospitals　醫院提供的參考數據

St Paul’s Hospital 聖保祿醫院

Median Charge 收費中位數　

  • Doctors’ fee 醫生費 Not provided 未提供
  • Hospital charge 醫院收費 Not provided 未提供
  • Total 總費 Not provided 未提供

Reference website

Cannosa Hospital 嘉諾撒醫院

Median Charge 收費中位數

  • Doctors’ fee 醫生費 Not provided 未提供
  • Hospital charge 醫院收費 Not provided 未提供
  • Total 總費 Not provided 未提供

Reference website

Baptist Hospital 浸會醫院

Median Charge 收費中位數

  • Doctors’ fee 醫生費 Not provided 未提供
  • Hospital charge 醫院收費 Not provided 未提供
  • Total 總費 Not provided 未提供

Reference website

Adventist Hospital 港安醫院

Median Charge 收費中位數

  • Doctors’ fee 醫生費 Not provided 未提供
  • Hospital charge 醫院收費 Not provided 未提供
  • Total 總費 Not provided 未提供

Reference website

Post-op care 術後照顧

  • Control inflammation with regular usage of anti-inflammatory drug.
  • Apply cool pad (not ice pad) to the knee 30min 3 times a day.
  • If you have Cool-Pulse, use it as instructed.
  • Keep the foot above chest (sleep with 2 pillows supporting the calf, lie on floor and put calf on chair)
  • Tighten up your thigh and calf muscle 10 repetitions every 2 hours when you are awake.
  • Push the knee back against a flat and hard surface to straighten it, to prevent joint contracture.
  • You can walk without crutches if just had reconstruction or menisectomy performed.
  • But, if meniscal repair or microfracture was performed, you will need crutches. Use crutches all the time and avoid weight bearing, including at home.
  • Stay home for first 3 days. Do not walk more than 3000 steps in first week, gradually increase to not more than 6000 steps a day in 2 weeks time.
  • The wound is covered by a waterproof dressing. After 2 weeks, you can shower after carefully remove the boot temporarily, but do not take bath or rub on it. Keep the dressing intact, there is no need to change it regularly.
Hamstring graft 將會用於重建的大腿後肌腱
Concommitant CFL tear 伴隨的跟腓韌帶撕裂
  • 定時服藥，控制發炎
  • 每天3次在膝蓋上敷涼墊（不是冰墊）30分鐘。
  • 如果您有Cool-Pulse，請按照指示使用它。
  • 將腳放高於胸部（躺下時用2個枕頭抬高小腿；平時躺在地上，將小腿放在椅子上）
  • 當不是睡覺時，每2小時收緊大腿和小腿肌肉10次。
  • 將膝蓋向後壓到平而堅硬的表面．例如窗台，避免關節萎縮。
  • 如果僅進行了前十字韌帶重建或半月板切除，就可直接入院，不需用拐杖走路。
  • 但是，如果同時進行了半月板修復或微骨折，則在任何時候都必須使用拐杖及避免負重，包括在家中或室內環境。
  • 始終在家使用拐杖，包括在家中。
  • 手術後頭三天不要留家休息。第一周不要走超過3000步，在2週內逐漸增加到每天不超過6000步。
  • 傷口已用防水敷料覆蓋。所以2星期後，您可以脫下固定靴淋浴，但不要浸澡或捽這敷料。你只需保持敷料完整，無需定期更換它。

Early Post-op Complication　手術後早期併發症

Notify surgeon in case you have

  • Persistent fever of more than 37.5 Celcius
  • Chills and rigor
  • Wound pain despite rest
  • Wound redness and swelling
  • Purulent discharge from wound
  • Calf pain
  • Ankle swelling, progressive
  • Sudden onset of shortness of breath
  • Chest pain

如發現以下情況，要立即通知醫生

  • 持續高燒（口探高於攝氏37.5度）
  • 發冷打顫
  • 無論運動或休息時，傷口痛楚都持續增加
  • 傷口持續發紅腫脹
  • 傷口有膿液
  • 小腿愈見痛楚
  • 小腿、腳踝和腿部腫脹持續增加
  • 突發性的氣促
  • 胸口突然疼痛
Concomittant talar neck near fracture伴隨距骨受傷
Concomittant talar neck near fracture伴隨距骨受傷
Operative wound 手術刀口
Operative wound 手術刀口

Rehabilitation after Day 14 手術後2週復健

Exercise of calf and thigh muscles:

  1. Quadriceps contraction:
    Sit on chair, with your cast on, straighten the knee, count 15 seconds, and then relax. Rest for 10 seconds and repeat 10 times.
    When you have regained strength, do light squat, hold 90 seconds, with interval rest, 10 repetitions, 4 times a day.
  2. Calf contraction:
    Sit on chair, tighten your calf muscle, count 15 seconds, and then relax. Rest for 10 seconds and repeat 10 times.
    When you have regained strength, do tip toe standing, hold 90 seconds, with interval rest, 10 repetitions, 4 times a day

Range of Motion exercise:

  • Put the foot on floor, slide the foot backward on floor, to increase knee bending angle.
  • Continue stretching exercise to ensure the knee is straight. You can compare to the normal side.

Further strengthening and return to sports:

  • You can sit in the office for a long hours in 3 weeks after the operation, and go running no earlier than 3 to 4 months.
  • Increase the amount of activity gradually and avoid strenuous exercise, especially running, kicking and jumping.
  • Sex life can start at 6 weeks after surgery.
  • Avoid excessive ankle fatigue within one year.

小腿和大腿肌肉的運動:

  1. 大腿四頭肌收縮：
    坐在椅子上，穿戴着石膏托或固定靴，全神貫注下伸直膝蓋，保持伸直並數15秒，然後放鬆。休息10秒鐘，重複10次。
    肌力漸恢復後，做淺蹲，保持90秒，間隔休息，重複10次，每天4次。
  2. 小腿收縮：
    坐在椅子上，收緊小腿肌肉，數15秒鐘，然後放鬆。休息10秒鐘，重複10次。
    肌力漸恢復後，做趾尖企，保持90秒，間隔休息，重複10次，每天4次。
    1.  

運動範圍：

  1. 將腳放到地板上，慢慢拉回，以增加膝屈曲角度。
  2. 繼續壓膝，避免膝關節萎縮。

進一步加強肌力並重返正常運動：

  1. 您可以在手術後3週返回辦公室坐較長時間。需超過3個月才開始跑步。
  2. 逐漸增加運動量，避免劇烈運動，尤其是跑步，踢腿和跳躍。
  3. 性生活可以在手術後6週開始。
  4. 一年內避免踝關節過度疲勞。
Reference 參考文獻
  1. Schreiber VM, van Eck CF, Fu FH. Anatomic Double-bundle ACL Reconstruction. Sports Med Arthrosc Rev. 2010 Mar;18(1):27-32 https://pubmed.ncbi.nlm.nih.gov/20160627/
  2. Araki D, Kuroda R, Kubo S, Fujita N, et al. A prospective randomised study of anatomical single-bundle versus double-bundle anterior cruciate ligament reconstruction: quantitative evaluation using an electromagnetic measurement system. Int Orthop. 2011 Mar;35(3):439-46. https://pubmed.ncbi.nlm.nih.gov/20734043/
  3. Nikolaos K Paschos. Anterior cruciate ligament reconstruction and knee osteoarthritis. World J Orthop. 2017 Mar 18; 8(3): 212–217. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359756/