Getting up close to an ACL surgery
Dec. 12, 2007
By Lara Boyko
Special to CSTV.com
Lara Boyko covers a variety of sports for CSTV.com.
With Anterior Cruciate Ligament (ACL) injuries being all too common in women's college basketball players these days, I figured it was time to witness first-hand the procedure that is helping players return to the court. After being referred to UCLA Orthopedic board-certified surgeon and athletic department team physician Dr. Sharon Hame through my own orthopedic doctor, it was all set. I hit the jackpot and the investigative reporter in me was going to be satiated by being allowed inside an operating room at UCLA to watch a live ACL reconstruction surgery. Cool!
Usually when you hear about ACL surgery, it is referred to as repair surgery. With all of the good intent that this has, more times than not, after a player has torn their ACL they undergo reconstructive surgery. What is the difference between reconstructive instead of repair surgery? As Dr. Hame explains, it's significant.
"There are some who propose repair, but the gold standard is reconstruction," said Hame. "Repair is very controversial and involves placing sutures through the ligament itself and where we find the origin of the ligament. The problem with repair is that we don't think it is as successful because the ligament itself is bathed in the synovial fluid in the knee and there is something in that fluid which prevents it from healing.
"Reconstruction means taking a tendon or a ligament from somewhere else - either that person or someone else - and putting it in the place of the torn ACL."
The day of the surgery started simple enough. I was to drive over to UCLA's campus and watch Dr. Hame perform the surgery.
No big deal, right?
With the assignment seeming so simple, I swiftly drove to Westwood armed with an open mind, a steno pad and a pen, ready for anything.
With the scrubs on, I found my way to the nurse's station and waited for Dr. Hame to finish the surgery she was in the middle of. It was interesting to see the doctors and nurses buzzing around attending to whatever stage of surgery a patient was in. Whether it was the pre-operation stage of explaining that the gown opening goes in the back and personal items go in the plastic bag or escorting loved ones in to see their family member who just came out of surgery.
Dr. Hame came out shortly thereafter, greeted me, explained a little bit about the type of surgery (there are several ACL reconstruction surgical procedures) and then introduced me to the patient - a female, who put on a brave face while saying hello. Yes, you could see she was scared, but then again, if you know that someone is about to slice open your knee, I think you would be slightly scared too.
About 10 minutes later, the anesthesiologist was administering the nerve block to the patient's right leg in preparation for the surgery. In almost a blink of an eye later, I found myself walking behind the patient with Dr. Hame and the other doctors as the patient was wheeled into the room.
Once in the room, I found the patient being put to sleep with anesthesia, the doctors doing their final pre-surgery preparation with a John Meyer song playing in the background. The scene looked more like something out of Grey's Anatomy instead of ER.
Once the patient was asleep from the anesthesia, the draping was placed over the body and around the knee that would be operated on and the doctors were finished with their pre-op procedures (which also included bending the knee and testing the flexibility of the leg), it was showtime and I had a front row seat thanks to one of the wheeled stools already in the room.
The actual procedure started by disinfecting not only the knee with iodine, but almost the entire leg and foot. Once the iodine was wiped off, Dr. Hame started the procedure by marking on the skin where the initial incision would be made shortly.
Now if you don't have a strong stomach, or just eaten something gooey or runny or messy, by now the image of the next steps of the procedure - a blade piercing through the patient's skin only to expose the layers of skin, blood vessels and ultimately the white fleshy body known as patella tendon (the strongest ligament in the knee) -- may prompt you to stop reading. In reality, it really isn't that bad.
Once the incision was made, another doctor in the room used a pair of claw-like tongs to help open up the incision so Dr. Hame could access the patella tendon. With the tendon exposed, Dr. Hame then marked it with dots to indicate where the incision should be made to harvest (cut out) the ligament.
To help the tendon be removed from the knee, a saw is utilized. I am not sure if it was the sound of the saw, the smell of a metal saw cutting through the tendon and bone or the visual of all of this happening was enough for me to feel like the room temperature had increased about 20 degrees and I was having trouble breathing. Since I was standing at this point so I could get a better angle on watching the surgeons work, I felt it was time to take a seat, before passing out and having to pay off the bets to those who thought I would either throw-up or pass-out during the procedure.
The saw didn't quite do the trick and cut through the fibers, so a small metal mallet was enlisted to help finish cutting out the ligament specimen. The sound of a mallet pounding on the butt end of the drill was unsettling, but I figured as long as I wasn't either doing the pounding or on the receiving end of the tendon removal at this point, all would be good.
With a small portion (approximately 50 millimeters) of the patella tendon removed from the body, this specimen resembled a piece of calamari (without the golden brown coating and red with blood), was taken from the operating table to a nearby smaller table. It is on this smaller table where the specimen is cleaned and prepared (complete with threads in the upper and lower ends of the tendon) to be inserted back into the patient's knee.
As the side table becomes busy with activity, Dr. Hame then inserts a probe into the incision. This probe has a small camera on it, which with the help of a nearby TV monitor that is also recording the images, Dr. Hame is able to check the different components of the knee, clean/remove any loose bodies (ACL remnants and fatty tissue) and determine the health of the meniscus. It is during this internal inspection of the knee that it is discovered that part of the meniscus has become detached. This detached meniscus is repaired -- through a process called lateral meniscus repair -- using two biodegradable screws that affix it back into place.
According to a 1999 study in the Journal of Athletic Training, four times more women than men collapse in pain from ACL injuries. In addition, this same study reports that 80 percent of all ACL tears occur when there is no contact by another player and instead, routine actions are often the trigger. Knowing this, I realized at this point of the surgery that unless more preventative measures are developed for female athletes, the trend of ACL injuries will not go away.
My thoughts quickly returned to the events taking place in the operating room which included watching a long metal rod being inserted through the incision opening, moving through the back-side of the knee and exiting through the upper part of the leg and about a palm-length above the top of the knee cap. Yes, this image of a rod sticking out of the upper and lower leg was disturbing. Yet after the inside of the knee was finished being prepared and marked for where the ligament would be inserted, this rod would be the guide to help maneuver the harvested and cleaned tendon into the right place for attachment to the femoral (upper) side of the knee bone.
After the patella tendon specimen having made its journey into the knee to its attachment location, the top part of the patella tendon is screwed into place with a metal screw. Now it was time for one of the assisting surgeons to bend and flex the knee 10 times to help the muscle create a new memory with the attached tendon. Once this was complete, it was time to screw the tendon to the lower part of the knee.
With the tendon in place from top to bottom, Dr. Hame uses the probe to check the new ACL and the threads used to guide the tendon into place are removed. With everything looking good, the only thing left to do is for the assistant surgeons to stitch and suture-up the incision.
The surgery is successful and now, the fun part of the process for the patient begins - rehabilitation.
"It's somewhere between six and nine months," said Hame of the rehab timeline. "There are people who have gone back earlier, but it's because the ligament itself has to go through a process. We call that ligamentization where the graft we put in there has to go through a process and it is not speeded up by anything. You may go back in four or six months, but the graft still has to do the same thing. It takes almost a year for that graft to really reincorporate."
With my first successful ACL surgery complete, it's time to scrub-out, put on my regular clothes and call it day.