ACL reconstruction

Definition

ACL reconstruction is surgery to replace the ligament in the center of your knee with a new ligament. The anterior cruciate ligament (ACL) keeps your shin bone (tibia) in place. A tear of this ligament can cause your knee to give way during physical activity.

Alternative Names

Anterior cruciate ligament repair

Description

You will probably receive general anesthesia right before surgery. This means you will be unconscious and unable to feel pain. Sometimes, other kinds of anesthesia are used for this surgery.

The tissue that will replace your damaged ACL will come from your own body or from a donor. A donor is a person who has died and, before death, chose to give all or part of their body to help others.

• Tissue taken from your own body is called an autograft. The two most common places to take tissue from are a tendon in your knee or your hamstring. Your hamstring is a tendon behind your knee.
• Tissue taken from a donor is called an allograft.

The procedure is usually done by knee arthroscopy. With arthroscopy, a tiny camera is inserted into the knee through a small incision (cut). The camera is connected to a video monitor in the operating room. Your surgeon will use the camera to check the ligaments and other tissues of your knee.

Your surgeon will make other small cuts around your knee and insert other medical. Your surgeon will repair any other damage found. Your surgeon then will replace your ACL by following these steps:

• The old ligament will be removed with a shaver or other instruments.
• If your own tissue is being used to make your new ACL, your surgeon will make a larger cut. Then, your surgeon will remove this tissue through the larger cut.
• Your surgeon will make tunnels in your bone to bring the new tissue through. This new tissue will be in the same place as your old ACL.
• Your surgeon will attach the new ligament to the bone with screws or other devices to hold it in place. As it heals, the bone tunnels fill in. This secures the new ligament more.

At the end of the surgery, your surgeon will close your incisions with sutures (stitches) and put a dressing on them. Most surgeons take pictures during the procedure from the video monitor so that afterward you can see what was found and what was done.

Why the Procedure Is Performed

We know that NOT treating a torn ACL can lead to tissue damage and early arthritis. ACL reconstruction may be recommended for these knee problems:

• Knee that gives way or feels unstable during daily activities
• Knee pain
• Inability to continue playing sports or other activities, especially ones with cutting or pivoting.
• Other ligaments are also injured.

Before choosing to have this surgery, you should understand the time and effort rehabilitation (recovery) will take. You will need to stick to a program for 4 to 6 months before you can return to full activity. The success of the surgery depends on your sticking with your rehabilitation program.

Risks

The risks for any anesthesia are:

• Allergic reactions to medicines
• Breathing problems

The risks for any surgery are:

• Bleeding
• Infection

Additional risks for this surgery are:

• Stiffness of the knee or lost a range of motion
• Failure of the surgery to relieve symptoms
• Failure of the ligament to heal
• Pain in the knee
• Weakness of the knee
• Blood clot in the leg
• Injury to a nearby blood vessel

Before the Procedure

Always tell your doctor or nurse what drugs you are taking, even drugs, supplements, or herbs you bought without a prescription.

During the 2 weeks before your surgery:

• You may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), naproxen (Naprosyn, Aleve), and other drugs.
• Ask your doctor which drugs you should still take on the day of your surgery.
• If you have diabetes, heart disease, or other medical conditions, your surgeon will ask you to see your doctor who treats you for these conditions.
• Tell your doctor if you have been drinking a lot of alcohol, more than 1 or 2 drinks a day.
• If you smoke, try to stop. Ask your doctor for help. Smoking can slow down wound and bone healing.
• Always let your doctor know about any cold, flu, fever, herpes breakout, or other illnesses you may have before your surgery.

On the day of your surgery:

• You will usually be asked not to drink or eat anything for 6 to 12 hours before the procedure.
• Take your drugs your doctor told you to take with a small sip of water.
• Your doctor or nurse will tell you when to arrive at the hospital.

After the Procedure

You will probably go home the day of your surgery. You may have to wear a knee brace for the first 1 to 4 weeks. You also may need crutches for 1 to 4 weeks. Most people are allowed to move their knee right after surgery to help prevent stiffness. You may need medicine to manage your pain.

Physical therapy can help many people regain motion and strength in their knee. Therapy can last 2 to 6 months.

How soon you return to work will depend on the kind of work you do. It can be anywhere from a few days to a few months. A full return to activities and sports usually takes 4 to 6 months.

Outlook (Prognosis)

ACL reconstruction is usually very successful. A torn ACL used to end the careers of many athletes. Now, improvements in the surgery and in rehabilitation provide much better results. These improvements include less pain and stiffness, fewer complications with the surgery itself, and faster recovery time. Most people will have a stable knee that does not give way after ACL reconstruction.

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References

Phillips BB. Arthroscopy of the lower extremity. In: Canale ST, Beatty JH, eds. Campbell's Operative Orthopaedics. 11th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 48.

Streich NA. Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes. Knee Surg Sports Traumatol Arthrosc. March 1, 2008;16(3): 232-8.