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ACL Reconstruction

ACL reconstruction, sometimes known as anterior cruciate ligament repair, is surgery to reconstruct a torn ligament in the knee joint.

The anterior cruciate ligament (ACL) is a tough cord of fibrous connective tissue that passes diagonally through the knee joint, connecting the femur (thigh bone) to the tibia (shin bone). Another ligament, the posterior cruciate ligament, passes through the joint in the opposite direction. Together they form an ‘X’ inside the joint. The purpose of the ACL, which is strong but not very flexible, is to keep the joint stable by limiting the rotation and forward movement of the tibia underneath the femur.

If the ACL is torn it must be surgically reconstructed to restore stability to the joint. The ligament cannot be stitched successfully as the tissue will not knit back together, so tissue from another tendon is used to replace the damaged ACL. This can be taken from your own leg or from a donor. Surgeons have varying views on the best tissue to use, as each has advantages and disadvantages, but it is generally felt that using a tendon from the patella, the kneecap, has the best outcome. Your surgeon will discuss this with you and ask questions about your lifestyle and type of work, as this information will help in making the decision.

Without surgery, ongoing and secondary problems with the knee are likely. If the joint remains unstable certain activities will be prohibited, such as sports. An unstable knee might prevent normal work being carried out, and continuing pain is possible. Uneven wear and tear on the joint increases the chances of developing arthritis.

The purpose of reconstructive surgery is to restore both the stability of the knee and the proper function of the ACL.

Considerations prior to surgery:
Deciding whether or not to have ACL reconstruction depends on various factors:
  • The extent of the injury.
  • Whether other tissues are also damaged and need repair.
  • Your activity level: If your work and leisure activities involve a lot of twisting and turning, or heavy manual work, all of which strain the knee, surgery might be recommended.
  • Age: Early surgery on young people runs the risk of damaging the growth plates, which might lead to bone growth problems. Growth plates are areas of cartilage that turn into bone with age. Your surgeon can choose to either modify the surgical procedure, or delay surgery until the bone is more mature.
ACL reconstruction is usually very successful, with up to 95% of patients recovering full stability and range of motion of the knee.

Having some physiotherapy prior to surgery so that the knee is not stiff and swollen tends to produce a better surgical outcome.

Surgery is normally performed using a procedure known as knee arthroscopy. This can usually be done on an outpatient basis.

You are given anesthesia so that you will be asleep during the surgery. The new ligament, the tissue graft, is prepared and kept ready. A very small camera is inserted into your knee joint through a small incision. This camera is connected to a monitor so the surgeon can clearly view the entire joint and its surrounding tissues. Some more small incisions are made around the knee to enable other instruments to be used.

The torn ligament is then removed. At the point of original attachment of the ACL, narrow tunnels are drilled into the femur and the tibia. The new ligament is then pulled through the tunnels and attached to the bones with special screws. As healing progresses the tunnels fill with new bone, securely anchoring the ligament in place.

When you wake up you may find that your knee is in a brace to keep it temporarily immobile.

Careful and thorough rehabilitation is crucial to the success of the surgery. You will be placed in the care of a physiotherapist who will monitor your progress and supervise exercises, but it is extremely important that you follow the regime exactly. Doing too much or too little will jeopardize your chances of a full recovery. You must expect to spend many months healing, rebuilding strength and regaining use of the joint.

Physiotherapy begins almost immediately after surgery, with you being encouraged to walk with the aid of crutches, to begin lifting your leg unaided, and to practice tightening the quadriceps muscles, which run from the hip to the knee. Your knee will be iced regularly to reduce swelling. You will then follow a graduated program of exercises designed to restore muscle activity and strength, which will protect the knee, and to regain range of motion in the joint.

A return to sports can be considered when:
  • There is no longer any pain or swelling
  • Full range of motion has been regained
  • Muscle strength has been restored
These will help your recovery, but only do them with the permission of your physiotherapist.
Ankle press:
Point and then flex the toes 25-50 times. Repeat several times a day.
Ankle circles:
Rotate the feet at the ankle, forming circles with the toes. Do 10 circles in one direction, then 10 circles in the opposite direction. Repeat several times a day.
Knee flex:
Lying on your back with your legs stretched out and together, slide the heel of the injured leg along the bed towards your buttock. Stop when you feel a gentle stretch. Hold for 10 seconds then slowly return the leg to straight. Repeat 5-10 times for 1 set. Build up to 3 sets.
Quad set:
Lying on your back with legs stretched out and together, press the back of the knee down onto the bed. Hold for 5-10 seconds then relax. Repeat 5-10 times for 1 set. Build up to 3 sets, depending on the level of comfort.
Leg raise:
Lying on your back and keeping the injured leg straight, raise it about 6 inches off the bed. Hold 5-10 seconds then slowly lower. Repeat 5-10 times, working up to 20 times for 1 set. Build up to 3 sets.

Braces and crutches:
You are likely to wear a brace for up to four weeks, although this will be removed when you are exercising. You may wear a passive motion device at night, which holds the knee and very slowly moves it through its full range of motion. This decreases the chance of your knee stiffening up overnight. You will also probably use crutches to begin with, to avoid putting too much weight on the knee.

Which brace you might wear will depend on your surgeon’s preference. Some recommend an adjustable rehabilitation brace, which can be locked to prevent any movement of the knee at all, or adjusted to allow a certain range of movement. Later, if returning to sports, a functional brace might be worn. These are not absolutely necessary, but athletes may feel more comfortable having a bit of extra support.
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