What is Anterior Cruciate Ligament (ACL) Reconstruction?
ACL reconstruction is a surgery to replace a torn anterior cruciate ligament (ACL) — a major ligament in your knee. ACL injuries most commonly occur during sports that involve sudden stops and changes in direction — such as soccer, football, basketball and volleyball.
Ligaments are strong bands of tissue that attach one bone to another bone. During ACL reconstruction, the torn ligament is removed and replaced with a band of tissue that usually connects muscle to bone (tendon). The graft tendon is taken from another part of your knee or from a deceased donor.
ACL reconstruction is an outpatient surgery that’s performed by a doctor who specializes in surgical procedures of the bones and joints (orthopedic surgeon).
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Before ACL Reconstruction Surgery
Why it’s done
The ACL — one of two ligaments that crosses the middle of the knee — connects your thighbone to your shinbone and helps stabilize your knee joint.
Most ACL injuries happen during sports and fitness activities that can put stress on the knee:
. Suddenly slowing down and changing direction (cutting)
. Pivoting with your foot firmly planted
. Landing from a jump incorrectly
. Stopping suddenly
. Receiving a direct blow to the knee
A course of physical therapy may successfully treat an ACL injury for people who are relatively inactive, engage in moderate exercise and recreational activities, or play sports that put less stress on the knees.
ACL reconstruction is generally recommended if:
. You’re an athlete and want to continue in your sport, especially if the sport involves jumping, cutting or pivoting.
. More than one ligament is injured
. You have a torn meniscus that requires repair
. The injury is causing your knee to buckle during everyday activities
. You’re young (though other factors, such as activity level and knee instability, are more important than age).
ACL reconstruction is a surgical procedure. And, as with any surgery, bleeding and infection at the surgical site are potential risks. Other risks associated with ACL reconstruction include:
. Knee pain or stiffness
. Poor healing of the graft
. Graft failure after returning to sport
Preparing for ACL reconstruction
Your surgeon is likely to delay surgery until any swelling has gone down and you’ve regained near-to-full range of movement in your knee. This might be within a couple of weeks after your injury, but it varies from person to person. You’re likely to be asked to follow a preoperative rehabilitation program during this time. This usually involves specific physiotherapy exercises designed to strengthen your leg muscles and improve your range of motion. It also incorporates more general light activities such as walking and swimming.
Your surgeon will explain what else you need to do to prepare for your operation. For example, if you smoke, you’ll be asked to stop because it increases your risk of getting a chest and wound infection, and slows healing time.
You’ll usually have the surgery as an out-patient (you won’t need to stay overnight), and you may have it under general or spinal anaesthesia. If you have a general anaesthetic, this means you’ll be asleep during the operation. With a spinal, you’ll stay awake but the lower part of your body will be numb. You’ll need someone who can drive you home after your operation and stay with you overnight.
If you’re having a general anaesthetic, you’ll need to stop eating and drinking for a set amount of time before your surgery. This is usually for around six hours before your operation, but you should be able to drink water up to two hours before. Follow your anaesthetist/doctor’s advice and if you have any questions, just ask.
On the day of your procedure, your surgeon will meet with you to check you are well and still happy to go ahead. The staff at the hospital will do any final checks and get you ready for surgery. This may include asking you to wear compression stockings, or having an injection of an anticlotting medicine to help prevent deep vein thrombosis (DVT).
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During ACL Reconstruction Surgery
What happens during an ACL reconstruction?
ACL reconstruction is usually done by keyhole or arthroscopic surgery, meaning it’s carried out through several small cuts into your knee. Once the anaesthetic has taken effect, your surgeon will make these cuts in the skin over your knee. They’ll use an arthroscope – a thin, flexible tube with a light and camera on the end of it – to see inside your knee.
The surgery involves replacing your torn ligament with a graft, which your surgeon will take first. The graft is usually a piece of tendon from another part of your knee, for example:
. Hamstrings, which are tendons at the back of your thigh
. The patellar tendon, which holds your kneecap in place
Sometimes, a graft from a donor may be used. This is called an allograft and will be collected before your surgery.
Your surgeon will then drill a tunnel through your upper shin bone and lower thigh bone. They’ll thread the graft in through the tunnel and fix it in place, usually with screws or staples. Before finishing the operation, your surgeon will make sure there is enough tension on the graft and that you have full range of movement in your knee. Then they’ll close the cuts with stitches or adhesive strips.
Your operation will usually last between one and three hours.
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After ACL Reconstruction Surgery
What to expect afterwards
You’ll need to rest until the effects of the anaesthetic have passed. You’re likely to have some pain, stiffness and discomfort as the anaesthetic wears off, but you’ll be offered pain relief as you need it.
You’ll be encouraged to get up and move around, and to put weight on your leg as soon as possible. You may be given crutches and a knee brace to help support you.
This operation is usually done as an out-patient procedure. This means you’ll be able to go home once the anaesthetic has worn off. However, you’ll need someone who can drive you home and stay with you overnight.
You’ll have dressings over the wounds around your knee. Before you go home, you’ll be given some advice about caring for your healing wounds, signs of infection to look out for and pain relief you can take at home. You’ll also be given a date for a follow-up appointment.
Having a general anaesthetic can really take it out of you. You might find that you’re not so co-ordinated or that it’s difficult to think clearly. This should pass within 24 hours. In the meantime, don’t drive, drink alcohol, operate machinery or make any important decisions.
Recovering from an ACL reconstruction
It usually takes about six months to a year to make a full recovery from ACL reconstruction. You’ll see a physiotherapist within the first few days after your operation, who will give you a rehabilitation program to follow with exercises specific to you. These will depend on many things, including the extent of the damage to your knee and the level of activity you’re hoping to get back to.
Following your rehabilitation program will help you get your full strength and range of motion back in your knee. Many people are able to progress to walking without crutches within about two weeks after surgery. It usually takes about six to nine months to be able to go back to playing sport. This varies from person to person though and will depend on the sport you play and how well you’re recovering. Some people wear a knee brace when they return to playing sport. However, they can be bulky and awkward to wear. You don’t need to wear one – it doesn’t seem to make a difference to how well your knee functions. But you might find that it helps build your confidence as your knee will feel supported.
During your recovery, you can take over-the-counter painkillers such as paracetamol or anti-inflammatory medicines such as ibuprofen. Make sure you read the patient information that comes with your medicine and if you have any questions, speak to your pharmacist for advice. You can also apply ice packs (or frozen peas wrapped in a towel) to your knee to help reduce pain and swelling. Don’t apply ice directly to your skin though, as it can damage it.
Your surgeon will be able to advise you about when you can return to work, driving, and other activities.