JOINT HORIZONS Mount Stuart Hospital
St Vincent's Road Torquay
Devon
TQ1 4UP
T: 01803 326688
F: 01803 322006
Anterior Cruciate Ligament Reconstruction
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The Anterior Cruciate Ligament (ACL) links the tibia (shinbone) to the femur (thighbone). It is situated in the middle of the knee and is important in stabilising the knee joint, particularly during sport when changing direction whilst running.
Twisting injuries such as with a bad tackle in football, rugby or falling whilst skiing commonly ruptures the ACL. Typically, the knee will 'give way' and there may be a 'popping' sensation. You may even find that you are not able to get up and walk. Typically your knee will swell over the next hour as the ruptured ends of the ligament bleed into the knee. If nothing is done the knee swelling will slowly settle over six weeks but if you return to sport you may have 'giving way' episodes similar to your initial injury, but not as severe, when you twist and turn. This may limit daily activities and sporting activities. Continued damage will result in osteoarthritis.
Diagnosis of ACL injury
The diagnosis depends on a clinical examination at which time the laxity of the ligament can be assessed (possibly with an MRI scan) to see if the cartilages are also damaged. It is often very difficult to examine a knee soon after the initial injury, as it is swollen and painful. In this case it is usual to arrange for an MRI scan and physiotherapy to settle the knee down. After a few weeks it is easier to examine the knee and to confirm the diagnosis without an MRI scan.
Are there any alternatives to surgery?
It is possible to rehabilitate your knee and get it working well after injury by a course of physiotherapy. Particularly to strengthen up the hamstring and quadriceps muscles to stop the knee giving way. A brace can be worn but this does not always successfully prevent giving way. If your demands are not high, for instance social tennis rather than league football, it may be possible to get back to your desired level of activity without surgery. However, if you demands are higher and typically if you are younger, physiotherapy is unlikely to make your knee stable enough to get back to your desired level of activity. At this point, surgery may be required. There is no age limit for this type of surgery.
What happens in surgery?
Anterior cruciate ligament (ACL) reconstruction surgery is an arthroscopic (keyhole) surgical procedure. The procedure involves excising the damaged ACL and replacing it with a graft of your own tissues. There are two graft options: either the central third of the patellar tendon below the kneecap, or the hamstring tendons. The choice of graft depends on the patient’s activities and job. The ACL graft is stronger than the original ACL. Despite the loss of these tendons your hamstring strength or patellar tendon will return almost to normal strength after rehabilitation. The minimal incisions will be at the front and side of your knee depending on which graft is to be used. There is no major advantage with either graft type.
The graft is threaded across the knee via 2 drill holes. The first drill hole enters the knee where the ACL attaches to the tibia and the second is across the knee in the femur, where the ACL is also attached. The surgery is of a minimally invasive technique.
The graft is pulled through the knee and fixed in place using special screws, which squeeze the graft against the side of the tunnel and hold it firmly in place in the tibia with dissolvable pin in the femur.
If there is a cartilage tear found at the time of surgery it can be either excised as in an arthroscopic meniscectomy or, if small, the cartilage can often be repaired.
What happens after surgery?
You can have an ACL reconstruction performed as a day case or with a one night stay in hospital. In day case surgery the knee is filled with local anaesthetic at the end of the operation to numb the pain. Your thigh muscles may also be numbed for less than 24 hours following the surgery. In which case you are advised not to fully weight-bear until the anaesthetic has worn off.
You will be mobilised by a physiotherapist using crutches and given some exercises to perform. You will require the crutches for the first couple of weeks only. You will wear a knee brace for the first 4 to 6 weeks following the surgery for mobilising; the brace can be removed when at rest. Your physiotherapy rehabilitation is split into three 3-month phases.
In the first 3 months you will regain a full range of movement mainly performing 'closed chain exercises'. These are exercises with your foot on the floor or a pedal of a stationary bike that do not over stress the healing graft. After 3 months the graft has healed strongly to the bone in the tunnels either side of the knee joint and your rehabilitation can progress.
Between 3 and 6 months you start sport specific exercises. You can begin 'open chain exercises' such as jogging in a straight line and progress to shuttle runs in the gym. You will also do 'proprioception' exercises to train the muscles to respond quickly.
Between 6 and 9 months you can return to sport specific training. You can return to football and rugby training but this should be none contact. You can return to gentler sports such as tennis at this time.
Finally at 9 months your rehabilitation is complete and you can return to your chosen sport with no restrictions.
Success rate of ACL reconstruction
90% of patients should be able to get back to their chosen sport after an ACL reconstruction. However, if you play a sport at a high level, i.e. club rugby or semi professional soccer, the chances of returning to your previous level are lower. When the rehabilitation is complete the graft should be as strong as the uninjured knee. Less than 5% of grafts fail or rupture.
Complications of the surgery
Many of the risks of the surgery are similar to those for Knee Arthroscopy surgery. The risks and rehabilitation will be discussed in full with your surgeon prior to the operation.
For more information you can download our ACL Surgery Advice Sheet (Microsoft Word file - 118KB)
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