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ACL Reconstruction

Introduction

The Anterior Cruciate Ligament is a fibrous band that connects the femur and tibia (thigh and shin bones), providing support and stability. As a major ligament in the knee, it is one of the most common sites of serious knee injury, usually caused by collision, overextension and twisting.

ACL reconstruction surgery is an arthroscopic (keyhole surgery) procedure designed to repair the torn, ruptured or separated ligament, restoring stability and support with the end goal of allowing you to return to sports or other high-intensity activities.

A torn ACL cannot heal by itself, and when left untreated can lead to recurrent knee injury and permanent damage to the cartilage and menisci (linings) of the knee joint.

When is surgery necessary?

Whether or not you need surgery will depend on the severity of your injury. ACL reconstruction surgery is usually recommended if the ligament is completely separated, if the knee is repeatedly giving way during activity, or if a previous injury is causing ongoing arthritic pain or stability issues.

You should therefore consider surgery if any of the following apply to your situation:

  • Repeated 'giving' or instability in the knee
  • An active lifestyle (e.g. sports, physical work) requiring a strong knee
  • Worsening pain or swelling from an old knee injury

Please note that sewing together a torn ACL, while effective in restoring some strength, will not make it heal. For the best results, a graft made of tendon is usually employed.

The decision to operate

While ACL reconstruction is a common procedure with around 90% long-term success rates, it is important that we level-headedly assess the risks and benefits of surgery before deciding to proceed.

Based on your description of the issue, a physical examination and x-ray and MRI scans, Dr. Letchford will work with you to determine whether surgery is the best option for you. If you feel that your quality of life or livelihood depends on being able to trust your knees, Dr. Letchford will take this strongly into consideration.

Helping you understand your options

Before deciding to go ahead with surgery, Dr. Letchford will take the time to talk with you about:

  • The outcome you want
  • The risks and benefits of surgery
  • The results you can expect

Dr. Letchford will only recommend surgery if both you and he are in agreement that it offers the best possible outcome for improving your pain and mobility issues.

About the procedure

What it involves

There are a number of surgical options for ACL reconstruction, based on what type of graft is used.

  • Patellar tendon autografts use a tendon and bone plug from the shin and knee cap.
  • Hamstring tendon autografts use tendons from the inner side of the knee.
  • Quadriceps tendon autografts use the middle third of the quadriceps tendon, along with a bone plug.
  • Allografts use donated tendons from cadavers.
  • Artificial grafts use man-made materials. They are usually a last resort.

 

Each of these options comes with pros and cons. Dr. Letchford will discuss with you the potential benefits and downsides of each option before deciding how to proceed.

The surgical procedure for ACL reconstruction usually follows a general pattern, as outlined below, regardless of what type of graft is chosen.

Before surgery, you will undergo physiotherapy to prepare your knee. Flexibility and strength post-surgery are a large factor in successfully regaining motion, so this is an important preliminary step.

  • Based on the anaesthetist's recommendation, you will be given either general or spinal anaesthesia (put to sleep or numbed from the waist down).
  • A few small incisions are made to accommodate the arthroscopic camera and surgical instruments.
  • The relevant tendon is harvested and prepared for grafting.
  • Any meniscal or cartilage tears/burrs are trimmed and smoothed.
  • The ACL stump is removed and the area is prepared to receive the graft.
  • Using a long needle, the graft is secured into place, using sutures, screws, buttons or staples.
  • Dr. Letchford will test the graft under tension and make sure the knee has good motion and stability.
  • The incisions are closed and a brace applied to the knee.

ACL injuries commonly coincide with meniscal (lining) tears and damage to the articular cartilage and collateral ligaments. Therefore, no two surgeries are ever the same, as the scope of repair and reconstruction depends on the extent of your injuries.

Hospital stay and recovery time

In-patient stay:          1 night
Walk (crutches):        Up to 2-4 weeks
Walk (unaided):        2-4 weeks
Sports:                      9-12 months

Possible risks and complications

ACL reconstruction surgery has a low incidence of complications; however it is important that you are fully aware of any dangers before proceeding.

Possible (though unlikely) complications can include infection, blood clots, wound or scar irritation or numbness, anterior knee pain, nerve damage, and failure of the graft requiring repeat arthroscopy.

Pre-operative checklist

Although ACL reconstruction is a relatively minor surgery, it is important that you follow the guidelines below.

  • Existing medications

You should cease taking any blood-thinning or anti-inflammatory drugs, as well as any herbal or natural remedies you're taking, at least 10 days before your surgery.

  • Medical evaluation

You will undergo a routine medical examination to make sure you are in good enough health for the operation, and to identify any factors that might cause problems down the line, including body weight and existing infections or skin conditions.

  • Dental evaluation

Dental work can introduce bacteria into the bloodstream. To protect against the chance of developing an infection, please have any dental work done well before or after your surgery. You may need to take preventative antibiotics for a few months to a few years after your surgery to protect against the risk of infection.

  • Further tests and blood work

In most cases, you will be given a thorough physical examination that may include a diagnostic arthroscopy to confirm you have actually torn or ruptured your ACL. Other than this, you will be sent for routine blood work to confirm you are healthy enough to undergo surgery. We may also perform heart checks or additional scans if the need arises.

Recovery, rehabilitation and precautions

  • Physiotherapy and exercise

Physiotherapy is absolutely crucial to the success of ACL reconstruction surgery. You will need to work with your physiotherapist both before and immediately after your operation in order to give you knee the best chance at regaining as much motion and strength as possible. Getting back to previous activity levels can take as long as 9-12 months, and will require strict adherence to your physiotherapist's exercise regimen.

  • Preventing infection

Make sure you change your dressing as instructed, and keep an eye out for any changes, including fever, chills, tenderness, excessive fluid, or increased pain, as these can indicate infection.

  • Preventing blood clots

You will be given a combination of anti-clotting drugs and pressure bandages to help prevent clots from forming. If you notice any shortness of breath or unexplained pain, contact a doctor immediately.

Further information

For more information on what to expect from your ACL reconstruction surgery, please take the time to read through the resources available at the American Academy of Orthopaedic Surgeons website.