Do I Need One or Two Surgeries for My Meniscus and ACL Tear?
ACL and Meniscus Tears: One Stage Surgery, or do we need two operations?
I get asked weekly whether an athlete’s injury will require just one surgery, or two. What often happens is the ACL tears from twisting, and as the rotation of the knee continues, the meniscus tears next, often resulting in the cushion cartilage being “flipped” up in to the wrong place, actually blocking the ability to fully straighten the knee.
You may have heard of this as a bucket handle tear, flipped meniscus, or even a locked knee. Now two things need to be repaired, the ACL and the meniscus.
Everybody I know wants to have everything done all at once, but the question is whether it is smart to do so.
Historically, these have often been done in two different settings. First the meniscus gets put back into place and sewn together. Rehab the knee for 6 weeks and come back to fix the ACL at that time.
Wait….what? Why would you do that?
Remember from some of our previous posts, that the most common complication from any of our surgeries is the buildup of scar tissue.
In fact, scar tissue that is bad enough that it needs more surgery occurs in about 4% of patients following arthroscopic surgery.
Meniscus repairs often need a much slower rehabilitation than an ACL reconstruction so the thought has been to decrease the risk of scarring by doing these in two stages.
The advantage of a two staged approach:
1. The ability to reduce the risk of scar tissue by minimizing the amount of surgery in the first stage.
2. Being able to evaluate the healing of the meniscus tear at the time of the ACL reconstruction.
3. More aggressive rehabilitation may be permitted following the ACL portion of the procedure as the meniscus will already be healed.
The two staged approach was popularized by Dr. Shelbourne back in 1993 and had been adopted as the standard of care for many years.
So, do we have to do this in two stages?
Back in the 1980s and 1990s, our surgical repairs of the meniscus often necessitated large incisions creating more trauma and much higher risk of scar tissue. The old two incision ACL reconstructions were also very painful and subsequently also increased the risk of scarring. We had to push people really hard in rehab to get their range of motion back because the surgeries hurt so darn much.
With 2016 techniques to repair the meniscus arthroscopically only, and minimally invasive ACL reconstruction techniques, often utilizing less painful graft choices, and better post operative pain control techniques, the risk of scar tissue forming is very much less than it ever has been.
Some postulate that the meniscus has the best chance of healing in the face of the growth factors released from the surgical trauma of an ACL reconstruction.
More and more of us seem to be comfortable with performing the majority of ACL and meniscus tears in one setting rather than two. Even in the NFL now, it is rare for these players to undergo a planned two stage repair and reconstruction.
We seem to have to slow people down in their rehab more than we have to push them as the pain from our reconstructions are so much better controlled.
So the decision between one stage or two stage reconstruction of your ACL and meniscus tear needs to be a shared decision between you and your surgeon. You'll be discussing the following:
Is the risk of scar tissue greater than the risk of a second anesthetic and surgery?
Does one strategy allow more reliable healing to take place than the other?
It may come down to the amount of trauma from the injury, the types of surgical techniques planned, and the surgeon’s comfort level or experience with one game plan over the other. In my practice, if the ACL and just one of the meniscus is torn, even if displaced, we will typically feel very comfortable with the predicted outcomes in a single stage procedure.