ACL Reconstruction

ACL Reconstruction surgery involves a general or spinal anaesthetic as a day case or overnight stay.

The procedure is usually performed arthroscopically (through keyhole surgery) and is aimed at replacing the deficient ACL with a graft ligament to stabilise the The procedure is usually performed arthroscopically (through keyhole surgery) and is aimed at replacing the deficient ACL with a graft ligament to stabilise the knee.

Mr Hunt usually uses the medial hamstring tendons (gracilis and semitendinosus tendons) as the graft to replace the torn ligament. Occasionally it is necessary to use the middle third of patella tendon (the tendon just below the kneecap, taken with a small piece of bone from the patella and the tibia).

The hamstring graft is harvested through a small incision (approximately 4 to 5cm) below the knee over the inner (medial) aspect of the shin .

The graft is inserted through a drill holes in the femur and tibia so that it lies in the same position as the original ACL did before it was injured. The graft is then held with screws or similar devices that do not require removal.

Post-operative management

ACL-recon1
ACL reconstruction in place
acl-tunnel1
Femoral tunnel for an ACL reconstruction

Most patients are able to return home on the same day as surgery or the following day.

Patients need to use crutches for the first two weeks following surgery although they can fully weight-bear – the crutches are mainly to prevent falls until good muscle control has been regained to the leg

All patients will need someone to take them home and be with them on the night following surgery.

Dressings

The large bandage around the knee is normally removed 24-48 hours after surgery and a tubigrip to supply gentle compression to reduce post-operative swelling

The non-stick sterile dressings on the wounds are replaced with clean waterproof dressings .

The larger incision over the site of the hamstring tendon harvest site is closed using dissolving stitches and the paper butterfly sutures overlying this can be peeled away easily after 10 days.

Bathing and showering

The wounds should be kept clean and dry until the wound has sealed. Showering is fine and the waterproof dressings can be changed afterwards. Bathing is best avoided until the wounds are sealed, typically 10 days after surgery.

In summary, whilst the wounds are wet – keep them dry and when the wounds are dry, you can get them wet!

Operative Technique

Rehabilitation

Surgery is followed by a prolonged course of physiotherapy. This requires a commitment to undertake this rehabilitation in order to achieve the best possible result (at least half an hour per day for 6 months).

It is vitally important to stay within the post-operative activity restrictions an physiotherapy guidelines to avoid damaging stretching your reconstructed ligament.

Return to work

The timing of your return to work depends on the type of work and your access, however, the following is a guide:

Desk work: as soon as pain allows and you can travel easily to and from work (2 weeks)

Light duties: if the job allows partial use of crutches or limited walking (2-5 weeks). If the job involves standing for prolonged walking, bending, lifting, stairs but no squatting (7-8 weeks)

Heavy duties: full squatting, heavy lifting, digging, in and out of heavy machinery, ladder work etc (3-4 months)

Driving: when you can walk without crutches or a limp and be in control of your vehicle (about 3-4 weeks).

Risks

ACL reconstruction is an extremely safe and reliable operation. However there is a risk of problems or complications with any surgery.

These risks include:

Infection can occur with any operation. Special precautions are taken during surgery to diminish this risk, however, the risk still exists but there is <1% chance of developing a serious infection (major wound breakdown, septic arthritis or osteomyelitis).

Injury to blood vessels or nerves. Major injuries to these structures are extremely rare, although it is not uncommon to develop some reduced sensation around the shin wound, this rarely causes a problem

Deep vein thrombosis (DVT/PE) (blood clots) can also occur as with all operations (<0.2% of a serious clot).  This does pose a definite but miniscule risk to life (<1:10000).

Stiffness of the knee joint after ACL surgery can result from a number of causes. Fortunately these are rare. Some individuals are predisposed to form excessive and thick scar tissue. This is treated by surgical excision of the scar tissue (0.5%)

All these risks are uncommon and in total, the chance of you or your knee being worse off in the long term is about or less than 1%.

Re-rupture can happen if excessive force occurs to the knee in the early post-operative period (performing the wrong activities too early).

Rupture can also occur at a later stage by another injury (4-5%).

If this occurs then the options remain the same – that is to either live around ongoing instability symptoms or to undergo revision ACL reconstruction.