ACL Reconstructive Surgery

ACL reconstructive surgery is a surgical procedure to replace the anterior cruciate ligament (ACL) in the knee. In this procedure, the ligament is replaced by grafting tissue from another part of the body. A common reason for an ACL reconstructive surgery is a sports injury to the knee. Reconstructing the ACL using tissue from elsewhere in the body restores function to the knee.

The procedure is performed with arthroscopy, a type of surgery that uses an arthroscope, a medical device inserted into a joint or organ that consists of a light, a tube and a lens. The arthroscope allows the physician to see inside the body to perform minimally-invasive surgery.

The ACL runs through the center of the knee, from the femur (thigh bone) to the tibia (shin bone). The major stabilizing force in the knee, the ACL allows a person to turn and change direction when walking and running. When a person’s ACL is torn or badly damaged, he or she will feel pain or a buckling sensation when attempting to change direction.

In most cases, ACL reconstructive surgery is successful and helps a patient return to his or her pre-injury athletic ability. Although recovery from an ACL reconstructive surgery requires physical therapy and hard work, today’s minimally invasive procedures allow for quicker healing and shorter recovery times.

ACL Reconstructive Surgery Procedure

ACL reconstructive surgery is performed using arthroscopy. In an arthroscopic procedure, the doctor performs the surgery by inserting a camera into the body and watching the surgical site on a video screen. The camera is attached to a tube the surgeon inserts through a small incision. Arthroscopy is less invasive than regular surgery, as only two small incisions are made, one for the arthroscope and one for the surgical instruments.

To perform an ACL reconstructive surgery the surgeon first removes the torn or injured anterior cruciate ligament. Next the surgeon reconstructs the ACL by grafting tissue from another part of the body to replace the ACL.

The most common tissues used for ACL reconstructive surgery are the patellar tendon in the knee and the semitendinosus and gracilis tendons in the hamstring. The procedure the surgeon uses will vary depending on which tendon is chosen for the graft. Advantages and disadvantages exist for both patellar and hamstring tendons. Your physician will be able to determine which procedure is best for your particular situation.

You will most likely receive general anesthesia, which means you will not be awake during the surgery. Reconstructive surgery using the patellar tendon is normally an outpatient procedure, but reconstruction using hamstring tendons may require a stay at a hospital.

ACL Reconstructive Surgery Using The Patellar Ligament

By far, the most common type of ACL reconstructive surgery uses the patellar tendon in the kneecap. This procedure was made popular in the mid-1980s and remains the preferred method of ACL reconstruction. Usually, the patellar tendon is harvested from the injured knee. However, the tendon from the uninjured knee or a tendon from a donor (allograft) may be used.

The physician harvests the donor tissue from the patellar tendon by cutting out the middle third of the tendon, along with a block of bone attached to each end. Next, the physician drills holes into the femur (thigh bone) and tibia (shin bone). The patellar tendon is threaded through and fixed into place with metal or bioabsorbable screws. Bioabsorbable screws eventually dissolve into the body. Immediately after surgery, the patient is able to apply pressure and movement to the knee without affecting the graft’s attachment to the thigh and shin bones.

ACL reconstructive surgery using the patellar tendon is a highly successful procedure, restoring most patients to pre-injury athletic ability. As an added bonus, this procedure is usually performed on an outpatient basis, requiring no stay at the hospital. However, the patellar tendon method does have some disadvantages.

Disadvantages include:

• A larger incision at the donor site than with the hamstring method
• Risk of breaking the patella (kneecap) during or shortly after surgery
• Increased wound pain after surgery
• More scarring
• Higher chance of tendonitis in the knee
• Increased risk of pain while kneeling even years after the surgery

ACL Reconstructive Surgery Using Hamstring Tendons

Quickly gaining popularity is an ACL reconstructive surgery method that uses tendons from the hamstring. This process uses the semitendinosus tendon alone or in combination with the gracilis tendon. Because these are not the main tendons that support the hamstring, the hamstring is still functional after they are removed. A common method uses both tendons folded over once and braided together, creating a quadruple band for a stronger graft.

Holes are drilled into the femur (thigh bone) and tibia (shin bone) at the middle of the knee joint. The holes make diagonal cuts through and out the side of each bone, creating one long diagonal tunnel for the grafted tendons. The hamstring tendons are then threaded through the holes in the femur and tibia and pulled up and out the side of each bone, where they are fastened with screws. In the past, this graft has not been as strong and secure immediately after surgery as that used in the patellar tendon method. However, advances in technology are improving graft fixation, such as the use of different types of screws.

As graft fixation has improved, ACL reconstructive surgery using hamstring tendons has gained a lot of attention. Some studies have shown its effectiveness as equal to the patellar tendon procedure.

Because the donor site requires a smaller incision, hamstring grafts result in less post-operative pain. This method also may result in less atrophy of the quadriceps, which may allow the patient to move through physical therapy quicker and return to sports faster. However, disadvantages also exist.

Disadvantages include:

• The need to immobilize the knee for a couple weeks after surgery
• Risk of some loss of hamstring strength

Autograft VS. Allograft Reconstructive Surgery

The tissue used to reconstruct your ACL may be an autograft, which is tissue from your own body, or an allograft, which is tissue from a donor, generally a cadaver.

Autografts are more commonly recommended, especially for a patient’s first ACL reconstructive surgery. However, sometimes an allograft is required, such as if there is a problem with the patient’s own tissue, if the patient is having multiple grafts or if the desired tissue was already used for a previous surgery.

Allografts do present some advantages. For example, if a patient receives an allograft, he or she will not experience donor site scarring and post-operative pain. In addition, the surgical time will be shorter.

Risks of an allograft include:

• Small risk of rejection by the body due to the introduction of a foreign material
• Risk of serious infection, such as hepatitis or HIV; however, testing mostly eliminates this risk
• Risk of less serious infection that can result in eventual arthritis or other problems with the graft
• Risk of weakened graft due to the irradiation process sometimes used to sterilize the tissue before grafting

Find an ACL Reconstructive Surgery Doctor

Finding the right surgeon can make all the difference in your ACL reconstructive surgery experience. We work hard to connect you with the best doctors in your area. Our physicians are skilled and qualified in cutting-edge reconstructive surgery techniques. They perform surgery in accredited medical facilities, keep abreast of the latest developments in their field, complete continuing education in reconstructive surgery and follow the highest standards in patient care and safety.

Click on “Surgeon Locator” to search our physician directory for a surgeon in your region. You can read about physicians’ credentials, visit their websites, learn about the reconstructive surgery procedures they perform and see pictures of their offices and patients.

The first step toward your ACL reconstructive surgery is setting up a consultation with a surgeon. During your consultation, your doctor will gather information about your medical history and ask you questions about your goals in pursuing reconstructive surgery. He or she will determine whether or not you are a candidate for surgery and which procedure will work best for your situation and produce the best results. The only way to know for certain if you are a candidate for reconstructive surgery is to meet with a qualified plastic surgeon.

The goal of reconstructive surgery is to improve your ability to accomplish everyday tasks, your sense of well-being and your life. We encourage you to take this important step by searching for a local doctor today.

Am I a Candidate For ACL Reconstructive Surgery?

You are likely a candidate for ACL reconstructive surgery if you have torn or partially torn your anterior cruciate ligament (ACL).

This ligament may be torn when you turn or pivot suddenly, decelerate or stop moving quickly, fall and land in certain ways or land badly after jumping. ACL injuries may occur when playing sports that require lots of sudden movements, pivoting, changing direction quickly, sprinting and contact with other players. For example, soccer and football players are susceptible to ACL injuries.

Only your doctor can determine for sure whether or not you are a candidate for ACL reconstructive surgery. If you experience the symptoms of a torn or injured ACL, you should have the knee examined by a doctor right away.

To determine the extent of damage, your doctor will examine your knee and talk to you about your symptoms. Although a doctor can determine whether an ACL is torn by conducting a physical examination, he or she may order x-rays or an MRI to determine whether damage has occurred in the bones, cartilage and other ligaments in the knee. Unfortunately, ACL tears often coincide with other damage, such as damage to the medial collateral ligament (MCL) and the meniscus cartilage.

In some cases, a doctor may determine that surgery is not needed for the patient to return to his or her normal activities and lead a comfortable life. Non-surgical treatment of an ACL injury includes anti-inflammatory medications and physical therapy to restore range of motion. However, if you are young, lead an active lifestyle or work a physically-demanding job, surgery is normally recommended. Although a person who leads a sedentary lifestyle may be able to perform normal daily activities comfortably without a reconstructed ACL, the nonsurgical route may lead to further damage of the knee in the future.

To be able to return to a physically-demanding sport, surgery is almost always necessary.

Symptoms Of a Torn ACL

If you experience the symptoms of a torn ACL, you should have a doctor examine your knee right away. Even if the symptoms go away on their own, your ACL’s strength and stability may be compromised and may lead to further damage. If left untreated, an injured ACL can also lead to early arthritis.

Symptoms of an injured ACL include:

• Pain and swelling within 24 hours of an injury
• Tenderness
• Loss of full range of motion of the knee
• A feeling of buckling or instability when pivoting or changing direction
• Discomfort when walking

ACL Reconstructive Surgery Risks

As with any surgical procedure, an ACL reconstructive surgery is not without risk. Risks that come with any surgery include:

• Risks of anesthesia, including allergic reactions
• Bleeding
• Infection

Risks of ACL reconstructive surgery include:

• Possible stiffness and pain in the knee
• Loss of some range of motion
• Weakness in the knee
• Failure of the ligament attachment and failure of the graft to heal
• Blood clots in the leg
• Injury to nearby blood vessels

Before ACL Reconstructive Surgery

Your doctor will conduct a physical examination to determine whether your ACL is torn and will require surgery. In addition, your doctor may order x-rays and an MRI to determine whether there is damage to bones, cartilage and other ligaments in your knee. If so, these may require surgical intervention as well.

Before your procedure, you should discuss with your doctor any drugs you take, including non-prescription drugs and supplements. It’s important that you are honest and upfront about your drug use, smoking habits and use of alcohol, as these substances may affect your recovery.

Your doctor will give you specific instructions regarding which medications you should stop temporarily and which you may continue taking. If you take maintenance drugs for a medical condition, such as heart disease or diabetes, you should discuss these medications and your upcoming surgery with the doctor who treats these conditions.

Your doctor will direct you to refrain from eating for a specified number of hours before your surgery and will give you further instructions to follow to prepare for your ACL reconstruction. It’s normal to be nervous before surgery. You must follow your doctor’s instructions carefully and be sure to ask him or her any questions you may have.

After ACL Reconstructive Surgery

In many cases, ACL reconstructive surgery is an outpatient procedure, so you will be able to return home the same day as your surgery. You should have someone with you to drive you home, as it will not be safe to drive after the anesthesia. You also may not be able to drive for a few weeks after your surgery.

Your doctor will dress your wounds and give you instructions for how to care for them until the incisions heal. Your doctor may prescribe medications to relieve pain. You can also discuss with your doctor which over-the-counter medications may help you manage your pain. Some post-surgery pain and discomfort is unavoidable, and your doctor can explain how much pain is normal and to be expected.

You may be required to wear a knee brace for the first few weeks after your surgery. Your doctor may also recommend crutches for the first week or several weeks. Most patients are able to move the knee right away, and movement can help prevent stiffness and aid recovery.

The graft normally takes about 6 weeks to heal. Although you may be able to walk around and perform some of your normal daily activities shortly after surgery, you should be cautious.

Some patients are able to return to work within a week. However, if your job is physically demanding, returning to work will take longer. Your doctor will be able to work with you to determine when you may safely return to work.

A full return to sports and other physically-demanding activities may take 4 to 6 months and will follow a physical therapy regiment that may last 2 to 4 months. Returning to sports too early is risky and may lead to further damage, so listen carefully to your doctor’s and physical therapist’s instructions.

Some athletes wear a brace on the treated knee during sports for years after the surgery, but many do not. Evidence is inconclusive whether a brace helps to prevent re-injury. You should discuss with your doctor whether he or she feels you will benefit from wearing a knee brace during exercise and sports.

Physical Therapy After ACL Reconstructive Surgery

An important part of ACL reconstructive surgery recovery is physical therapy. Returning to sports and other high-impact activities too soon can cause injury, so it’s important to carefully follow your physical therapist’s instructions exactly.

Shortly after your surgery, you will be instructed to do range-of-motion exercises that do not put pressure on the knee but help to keep the ligament flexible and reduce stiffness. Physical therapy will begin after the graft has healed, which normally takes 6 weeks. Your first physical therapy exercises will be for strength and flexibility. After about 12 weeks, you will be able to engage in more aggressive exercises and your physical therapist may allow you to do light jogging. After about 4 months, your physical therapist may have you do more intense activities, such as running.

Returning to sport-specific activities, such as foot work and ball work, will occur next, when your therapist feels you are ready and your knee is strong enough. A full return to sports may occur around 6 months, depending on your progress.

ACL Reconstructive Surgery Results

ACL reconstructive surgery is generally very successful. Although a torn ACL used to end an athlete’s career or seriously impact a person’s well-being, advances in technology have led to a high success rate of ACL reconstruction and a return to sports and other activities for a majority of patients. In fact, studies show an 82 – 95% long-term success rate after ACL reconstructive surgery.

Results depend on your commitment to physical therapy and exercise to regain full use of your knee. You must be willing to put in the hard work that therapy requires and to follow the instructions of your physician and physical therapist exactly.