ACL reconstruction

What is an ACL reconstruction?

ACL (anterior cruciate ligament) reconstruction is a keyhole procedure in which the remaining fragments of a torn ACL are removed and a new ACL is reconstructed using graft tissue and fixed inside the knee. The graft tissue used is normally your own hamstrings tendon or in certain circumstances a section of patella tendon.

I have an ACL tear, do I require an ACL reconstruction?

Not everyone who tears his or her ACL requires reconstructive surgery. Some individuals are able to function well by strengthening their knee with physiotherapy and therefore don’t require surgery.

In contrast to this some individuals find that despite physiotherapy their knee gives way or feels unstable with simple day-to-day activities. In those individuals, if otherwise fit for surgery, then reconstruction is usually the preferred option.

In a third group of people the feeling of instability might only occur when undergoing certain activities or manoeuvres such as during football. In this situation he or she might decide to either avoid the sports or activities that make their knee feel unstable or consider ACL reconstruction with an aim to get back to those types of activity.

The recommended treatment of a torn ACL varies between individuals. If you have an unstable feeling in your knee and if you are an active individual you may decide to have the ACL reconstructed. The young sportsperson involved in twisting / turning sports is most likely to require surgical reconstruction.

Some point to consider include:

How unstable is your knee? / Does your knee ‘give way’ on a regular basis?
What is your occupation? / Does your knee feel unstable at work?
How often do you play sport? / What type of sports do you enjoy?
How is your general health?
Can you commit time to the rehabilitation programme?
Are there any associated knee injuries?
(For example ACL reconstruction may be more likely to be recommended if there is an associated injury such as a large meniscus tear or following meniscal repair).

Are there non-surgical options for a torn ACL?

A torn ACL doesn’t ever heal. However, some people may have no on-going symptoms from their ACL tear, or they may not be very active and wish to avoid surgery.

Physiotherapy is helpful to strengthen the knee following injury. Strengthen the leg muscles (particularly the quadriceps and hamstring muscles of the thigh) can help to support the knee and give it a feeling of stability.

An ACL specific knee brace can be worn when carrying out certain activities, such as skiing or climbing and provide the knee with some additional support.

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What does the procedure involve?

The aim of ACL reconstructive surgery is to stabilise the knee and therefore prevent further knee injury, such as meniscal tears.

ACL reconstruction is a keyhole (arthroscopic) procedure in which a tissue graft (most often your own hamstrings tendon) is used to replace the torn ACL.

The procedure is usually carried out under a general anaesthetic as a day case. The hamstring tendon graft is taken from the same knee through a small wound over the front of the upper part of the shinbone. An arthroscopy (keyhole assessment) of the knee is first carried out to assess the joint surface and look for associated meniscus (cartilage) tears that may require treatment.

Tunnels are drilled in the tibia (shinbone) and femur (thighbone). The hamstring tendon, which has been stitched into the shape of a new ACL ligament, is then passed via the tunnels across the knee and fixed firmly to the bone on either side of the knee joint. The new ACL graft acts to provide stability to the knee joint.

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The wounds are usually closed with clips and a bandage is applied to the knee. You will be reviewed by the physiotherapist on the same day as your surgery and with their help start to mobilise with crutches.

Post-operative ACL rehabilitation

Good post-operative rehabilitation is vital to a achieving a good outcome following surgery. You will be required to work hard with the physiotherapists and on your own with specific exercises following your surgery.

In the initial phase the aim of the rehabilitation is to regain a good range of motion in the knee and get the leg muscles working well.

You will then work on a knee-strengthening regime, protecting the new ACL graft, gradually increasing the stress across the ligament.

Finally the rehabilitation will be tailored towards getting you back to your sport of choice.

What are the risks associated with ACL reconstruction?

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All surgical procedures carry some degree of risk as well as benefit. Generally the risk associated with ACL surgery is low. There is a small risk of infection associated with any operation; it is very low (say 1% or 1 in 100) with ACL surgery. Care is taken to try to minimise the risk of infection. There is a small risk of stiffness with surgery.

Re-rupture of the graft is a potential risk factor (the risk is similar to rupturing the ligament in the other knee). In order to try to reduce the risk it is really important to work hard with the physiotherapists and gradually build back up the level of activity on the knee. There is an increased risk of re-rupturing the graft if you go back ‘to quickly too soon’. This will be discussed with you in more detail prior to surgery.

What should I expect following my knee arthroscopy?

There will be some localised knee swelling following the surgery. This can be helped by trying to rest the leg over the first few days following your surgery, keeping the leg elevated (raised) and applying ice or cold packs to the knee to keep the swelling down. The swelling will naturally go down with time.

The wounds are usually closed with clips and a bandage is applied to the knee. The bandage should be left alone for 48 hours, after which point it can be taken off to the leave the small sticky plasters which will be covering your wounds. The small wounds should be covered with sticky plasters until they have healed over. The skin clips are usually taken out at around 10 days following the surgery.

You will be reviewed by the physiotherapist on the same day as your surgery and with their help start to mobilise using crutches initially. You will be kept under close review by the physiotherapists who will work closely with you through your ACL rehabilitation.

Post-operative ACL rehabilitation

Good post-operative rehabilitation is vital to a achieving a good outcome following surgery. You will be required to work hard with the physiotherapists and on your own with specific exercises following your surgery.

In the initial phase the aim of the rehabilitation is to regain a good range of motion in the knee and get the leg muscles working well.

You will then work on a knee-strengthening regime, protecting the new ACL graft, gradually increasing the stress across the ligament.

Finally the rehabilitation will be tailored towards getting you back to your sport of choice.

When can I return to work following ACL reconstruction?

As a general rule you will be off work for three weeks for desk-based job and three months for a manual job.

When can I drive following my knee surgery?

There is no set time frame for getting back to driving following surgery. You must be able to demonstrate that you are safe to drive, (i.e. can carry out an ‘emergency stop’ and handle the vehicle safely at all times). This will vary on an individual basis.