ANTERIOR CRUCIATE LIGAMENT (ACL) REPAIR

​

Anterior cruciate ligament (ACL) repair is a surgical procedure to reconstruct or repair a torn ACL in the knee. The ACL is one of the four main ligaments in the knee that connects the femur (thigh bone) to the tibia (shin bone), providing stability and allowing for proper knee movement. ACL injuries are common in athletes and can occur due to sudden changes in direction, awkward landings, or direct contact to the knee.

​

• The cruciate ligaments support the knee anteriorly and posteriorly

• The collateral ligaments support the knee medially and laterally

​

There are 4 types of grafts::

​

• Autografts: from the patient's own body

• Allografts: from cadavers

• Xenografts:  from animals

• Synthetics (high rate of complications)

​

Postoperative care and rehabilitation are crucial for a successful recovery. Patients typically participate in physical therapy, starting with gentle range-of-motion exercises and gradually progressing to strength training and sport-specific exercises. The rehabilitation process can take anywhere from six months to a year or more, depending on the individual and the extent of the injury.

​

                                                                                                 

                                                                Anesthetic Implications for ACL repair

​

Anesthesia type: General ETT or LMA, peripheral nerve block or neuraxial anesthesia (spinal or epidural with IV sedation)

​

Airway: Endotracheal tube or LMA

​​

Preoperative:

​​​

• Trauma is the most common cause of knee ligament tears

• Trauma patients with sports injuries are often young and healthy

• Osteoarthritis and rheumatoid arthritis can also cause tears.

• Regional is associated with decreased blood loss, decreased risk of DVT, minimal respiratory impairment, and effective postop analgesia.

​​

Intraoperative:

​

• ACL repair is commonly done arthroscopically

• Tourniquet is used

• Tourniquet is usually set 100 mm Hg above the patient’s systolic blood pressure

• Maximum safe tourniquet time is less than 2 hours to prevent injury

• Chart the tourniquet time and location

• MAP commonly drops by approximately 20% after tourniquet deflation

• ​Position: Supine with arms out

• EBL: Expect 50-200 ml

• The femoral nerve block does not cover the posterior portion of the knee

• The sciatic nerve block covers the posterior portion of the knee

• Ketorolac (Toradol) provides analgesic and antiinflammatory properties by inhibiting prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase (early component of arachidonic acid cascade) 

• NSAIDs have been shown to decrease bone formation in spine fusions and rotator cuff surgery

​

Postoperative:

 

• ​Maintain knee immobilization with a knee immobilizer

• Femoral nerve block (FNB) is an effective analgesic technique for ACL reconstruction; however, it weakens the quadriceps muscle.

• The adductor canal block (ACB) is a distal block of the femoral nerve that preserves the strength of the quadriceps femoris muscle

​

Complications:

​

• Embolus

• Bleeding

• Infection

• Thrombophlebitis

• Tourniquet-related nerve injury​

​

Sources:

​

Elisha, S. (2010). Case Studies in Nurse Anesthesia.

 

Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

​

Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

​

​

​

​

​

​

 

​​

​​