The Anterior Cruciate Ligament (ACL) is one of the major stabilising ligaments in the knee. It is a strong ribbon-like structure located in the centre of the knee, running from the femur to the tibia.
Unfortunately, when this ligament tears, it doesn’t heal and often leads to instability in the knee.
The ACL prevents the tibia (shin bone) from moving abnormally on the femur (thigh bone). When this abnormal knee movement occurs, it is referred to as knee instability, and the patient is aware of it.
Often, other structures such as the meniscus, the articular cartilage (lining the joint) or other ligaments can also be damaged simultaneously as a cruciate injury. These may need to be addressed at the time of surgery.
ACL reconstruction is a surgical procedure that aims to replace a damaged or torn ACL with a new ligament. In some cases, the new ligament is typically taken from other tendons of the patient's body or a donor. This surgery can now be performed with minimal incisions and low complication rates.
If you have experienced an ACL tear or damage, and your symptoms have not improved with non-surgical treatments, you may be a good candidate for ACL Reconstruction. You may also be suitable for this procedure if you have a highly active lifestyle or participate in sports requiring sudden direction or pivoting changes. After a thorough evaluation and diagnostic testing, an orthopaedic surgeon can determine if ACL Reconstruction is the best option for you.
There are several benefits of ACL reconstruction. Firstly, it can help to restore knee stability and function, allowing you to resume daily activities or sports without pain or discomfort. Secondly, it can prevent long-term complications such as arthritis or meniscus tears. Thirdly, it can improve your quality of life and overall well-being by reducing the risk of further knee injuries and the need for future surgical interventions.
Repair involves keeping the original ligament by directly suturing the two ends of the rupture together. Attempts at repair of ACL tears are now largely historical due to the high rate of failure of the surgery. However, advanced new techniques are showing promising results to allow repair rather than reconstruction in some cases. Better quality studies are still to come to support the repair techniques.
All ACL surgery nowadays is a reconstruction. This involves replacing the damaged tissue with a substitute tissue called a graft. The most commonly used grafts involve tissue from the patient (autografts). Tissue from donor patients (allografts) can also be used.
The most commonly used autografts are
There are pros and cons for each option. All three options are suitable and are associated with good results.
There are pros and cons of using cadaver tendons.
Pros
Cons
Essentially, allografts are options when there is no viable autograft (own patient tissue) to be used, such as multiple previous surgeries and usage of autograft prior.
Before undergoing ACL reconstruction surgery, you should undergo several tests to assess the extent of the injury and determine the best course of treatment. These tests include a physical examination, X-rays, MRIs, and blood tests. Your surgeon will also review your medical history and provide pre-operative instructions, such as avoiding food and drink for a certain period before the surgery.
Surgery is performed as a day procedure or overnight stay.
The surgery usually takes between 60–90 minutes.
Surgical techniques have improved significantly over the last decade, complications are reduced, and recovery is much quicker than in the past.
The surgery is performed arthroscopically.
Lateral tenodesis consist of an extra-articular procedure performed in some cases where the Antero-Lateral Ligament (ALL) is suspected to be torn, as well as the ACL. This ligament has been shown to contribute to anterolateral instability, mostly seen when the ACL is torn in some cases, depending on physical examination.
Lateral tenodesis consist of an open procedure performed to a small 5-10 cm incision on the lateral aspect of the knee. The IlioTibial Band (ITB) is used as a graft to augment the deficient ALL and to improve rotational stability and outcomes.
Recent High-Level literature has demonstrated that the Extra-articular procedures improved stability, patient-reported outcomes and 3x reduction in the risk of graft re-rupture.
Lateral tenodesis is indicated for some patients with increased risk of graft re-rupture after ACL reconstruction, such as
Ask your surgeon if you would benefit from Extra-articular procedures / Lateral tenodesis
See link attached for full ACL Rehab Protocol.
You will have pain medication by tablet or in a drip (intravenous).
A splint is sometimes used for comfort.
Leave any waterproof dressings on your knee until your post-op review.
The first review will usually be after 10-14 days.
You will be seen by a physiotherapist who will teach you to use crutches and show you some simple exercises at home.
Exercise and therapy can begin after a few days or be arranged at your first post-op visit.
If you have any redness around the wound or increasing pain in the knee, or you have a temperature or feel unwell, you should contact your surgeon as soon as possible.
Physiotherapy is integral to the treatment and should start as early as possible. Pre-operative physiotherapy helps prepare the knee for surgery better. The early aim is to regain range of motion, especially your full extension, reduce swelling and achieve full weight-bearing.
The remaining rehabilitation will be supervised by a physiotherapist and involve bike riding, swimming, proprioceptive exercises and muscle strengthening. Cycling can begin at two months; jogging generally begins at around three months. The graft is strong enough to allow sport at around six months. However, other factors come into play, such as confidence, fitness and adequate training.
Professional athletes often return at six months, but recreational athletes may take 10 -12 months, depending on motivation and time put into rehabilitation.
The rehabilitation and overall success of the procedure can be affected by associated injuries to the knee, such as damage to the meniscus, articular cartilage or other ligaments.
Like any surgery, anterior cruciate ligament reconstruction has risks. Some of the potential complications include
The risk of complications is generally low, and most patients experience a successful outcome. However, it is essential to discuss the risks and benefits of the surgery with an orthopaedic surgeon before deciding to undergo the procedure.
The prognosis of ACL reconstruction is generally good, with a success rate of over 90%. Most patients experience significant improvement in knee function and return to their regular activities or sports within six to twelve months after surgery. However, the success rate depends on various factors, such as the extent of the injury, the age and activity level of the patient, and adherence to post-operative rehabilitation protocols.
If ACL reconstruction is delayed, it can increase the risk of further knee damage and long-term complications such as arthritis and meniscal tears. Delayed surgery can also lead to prolonged recovery times and reduced knee function. In some cases, the damage may be irreparable, and the patient may require more extensive surgery or permanent knee bracing. Therefore, seeking prompt medical attention and following the recommended treatment plan is essential.
About Dr LEIE
An Orthopaedic Surgeon specialising in hips and knees who is dedicated to ligament reconstruction of the knee, cartilage restoration procedures, robotic knee (total and partial) and robotic hip replacements.
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