Anterior Cruciate Ligament Reconstruction

About the knee joint and cruciate ligaments

The knee joint is a complex hinge joint formed by the ends of the femur (thighbone) which has two smooth rounded joint surfaces and tibia (shinbone) with a flat surface.
Between these two joint surfaces are stabilising ligaments which make a cross, and are known as the cruciate ligaments. One ligament starts at the front of the knee (called the anterior cruciate ligament or ACL) and one starts at the back of the knee (called the posterior cruciate ligament or PCL). The cruciate ligaments keep the femur and tibia aligned as you bend and straighten the knee.
The patella (knee-cap) is the bone which sits at the front of the knee embedded in a tendon which runs from the thigh muscles (quadriceps) to the front of the tibia. This is known as the quadriceps tendon above the knee-cap and changes its name to the patellar tendon below the knee-cap. This patellar tendon can occasionally be used to reconstruct a new ACL.
Finally, the tendons of the hamstring muscles run behind the knee and can also be used as an alternative for ACL reconstruction.

What is an ACL rupture?

The Anterior cruciate ligament (ACL) is one of the most important ‘stabilisers’ of the knee joint. If you have torn (ruptured) this ligament, the knee can collapse or ‘give way’ during twisting or turning movements.

How does it happen?

It normally occurs as a result of a twisting injury to the knee. The common causes are football and skiing injuries. You can also injure other parts of the knee joint at the same time, such as tearing cartilage or damaging the joint surface.

What are the aims of surgery?

The aim of the operation is to reconstruct the torn ligament with one or more tendons taken from your knee (known as grafts). Either hamstring or patellar tendon can be used as a graft.

What are the benefits of ACL reconstructive surgery?

If the ACL reconstructive surgery is successful, your knee should feel more stable and not give way any more. This will allow you to be more active and return to some or all of your sporting activities. It may also reduce the chance of arthritis of the knee when you are older.

Are there any alternatives to surgery?

Your physiotherapist can teach you specific exercises to strengthen and improve the co-ordination of your thigh muscles which can often stop the knee giving way during everyday activities. Wearing a knee brace during sports can sometimes help.

What if you do nothing?

Without surgery the ligament will not repair itself. The knee may become increasingly unstable with time, leading to further damage and the risk of arthritis.

Who should have it done?

You should have the ACL reconstruction if your ligament is completely torn and:

  • you participate in vigorous sports such as football or skiing
  • your knee is persistently unstable during day-to-day activities even after a course of physiotherapy.

Who should not have it done?

You should not have the operation if:

  • You already have significant arthritis in the knee joint
  • You are not prepared to undergo the rehabilitation that follows the operation

What does the operation involve?

There are a variety of possible anaesthetic techniques. The surgery normally takes 60 to 90 minutes.
Your surgeon will make one or more cuts on the front and sides of the knee. Some surgeons will perform the operation by arthroscopic (‘keyhole’) surgery using a camera to see inside the knee.
Your surgeon will remove the old residual ACL and replace it with suitable tissue (‘graft’) from elsewhere. The top and bottom ends of the replacement graft are fixed with special screws or anchors into ‘tunnels’ drilled in the bone.

What complications can happen?

  • General complications of any operation:
    • Bleeding
    • Pain
    • Wound infection
    • Blood clots
    • Unsightly Scar
  • Specific complications of this operation:
    • Graft re-tears or re-ruptures causing recurrent instability
    • Knee joint infection
    • Damage to nerves around the knee
    • Loss of knee movement
    • Pain, stiffness and loss of use of the knee (complex regional pain syndrome)

How soon will I recover?

Normally you can go home the same day or the next day. Your surgeon may want you to wear a knee brace for a few weeks after the surgery. Once the knee settles down you will start intensive physiotherapy treatment which may continue for up to six months.
Regular exercise should help you to return to normal activities as soon as possible but you should consult your GP or a member of the healthcare team before starting exercise. It is unlikely your knee will ever be quite as good as before the original injury.

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