ACL reconstruction is carried out on people who have a complete tear of their ACL. This has often but not always been confirmed using an MRI scan prior to surgery. Not everyone with an ACL tear will require surgery; it depends on your age and sporting demands. Alternatives to surgery include physiotherapy, bracing and activity modification.
Usually you will be complaining of instability whereby the leg gives way when you go to turn on it. Sometimes patients have a feeling that they don't trust their knee.
Other problems such as meniscal tears will also be addressed at the time of the surgery.
It is important that your knee has settled down prior to surgery i.e that the swelling is minimal and that you have minimal pain and a full range of motion in the knee.
ACL reconstruction is usually performed under a general anaesthetic i.e you are fully put to sleep for the duration of the operation. Occasionally, a spinal anaesthetic may be used whereby the legs are numbed from an injection of local anaesthetic into your back however this can be discussed with the Anaesthetist prior to surgery.
The 2 main grafts used are patellar tendon and hamstrings tendons. Prior to surgery, you will have a discussion over which is best for you.
The patellar tendon graft involves removing the central third of the tendon with a piece of bone attached to each end from the patella and tibia respectively. It is probably the most robust graft but can be a little harder to recover from and can cause some pain around the front of the knee. Patients who kneel a lot such as roofers / tilers may wish to avoid this.
The hamstrings graft uses 2 of the small hamstrings tendons at the back of your leg. These are folded over to create a four strand graft. The effect on hamstring strength is minimal (10% deficit). Recovery is usually a little easier but overall re-rupture rates are a little higher.
A tight band or tourniquet is inflated around your thigh to ensure a bloodless view during the surgery. Occasionally your thigh may be mildly uncomfortable or look bruised after surgery because of this.
First of all the graft is harvested through either an incision over the front of the patellar tendon (Patellar tendon graft) or just to the inside of it (hamstrings graft). The graft is then cleaned and sized so that appropriate tunnels can be drilled.
A stab incision allows the camera to be introduced into the knee. A second stab incision allows instruments such as a probe or shaver to be inserted. In addition, the joint itself is filled with sterile fluid to make it easier to fully assess the joint and perform any tasks deemed necessary. After the knee is inspected and any necessary repair or excision of the menisci performed, the central area or notch is cleaned out to make way for the new graft. A tunnel is carefully drilled in both the femur and tibia bones using special guides to accurately locate their position in the knee.
The graft is then pulled up through the tibia and out through the femur and secured at either end. Any debris from drilling the holes is thoroughly cleaned out of the knee and the incisions are closed. Local anaesthetic is injected into the joint and the dressings applied.
Normally 2 but up to 4 scars will be present around the kneecap depending on the exact procedure performed. These will be approximately 1 cm long. They are closed with paper stitches (steristrips) that can be removed 7 to 10 days after the surgery.
The bulky wool & crepe bandage can be removed 24 hours after surgery. It is normal for the waterproof dressings underneath to have a small amount of blood on them and they can be replaced at this point. It is fine to shower but avoid getting too much water directly on the dressings. Some of the fluid that was used to fill the knee joint during the surgery can also leak out in the first couple of days and this is normal.
At the end of the procedure, some local anaesthetic is injected into the knee joint. This will usually but not always ensure minimal pain following the surgery. However, as the local anaesthetic begins to wear off (usually approximately 12 - 24 hours post surgery), some discomfort can return. Simple analgesia such as Paracetamol or Paracetamol with codeine or occasionally an anti-inflammatory should suffice at this point.
Whilst early activity is generally encouraged, you may also find that elevating the leg and placing an ice pack (or bag of frozen peas), wrapped in a towel, across the knee greatly helps to alleviate both pain and swelling.
Obviously this depends on both the individual & nature of the work. As a rule, an office worker can expect to return to work after 2 - 3 days whereas a manual worker may require 1 - 2 weeks off. Whilst a return to normal activities is in general recommended, an increase in pain and / or swelling may simply mean that activities need to be reduced somewhat for a couple of days.
Obviously this depends on the exact nature of the procedure, the activity involved and the level of athlete and if you have any doubts / questions feel free to discuss them with your consultant.
🏊🏼 Swimming is not recommended for the first 2 weeks after surgery until the wounds have healed. You can go for short walks 1 - 2 days after surgery & begin to build this up over the next week.
🚴🏻 After approximately 10 days, you can use an exercise bike and 2 weeks following surgery, you can start some light jogging or cross training.
Regarding field sports such as gaelic, hurling, rugby , soccer and hockey, you should aim to return around 9 to 12 months after surgery. An earlier return is occasionally possible but is associated with a higher risk of re-rupture.
You will usually be reviewed 2 weeks following surgery. This allows us to ensure that the incisions are healing and remove any dressings if necessary. It is often the best time to have a talk about the procedure itself and ask any questions regarding returning to normal activities and / or implications for the future.
Although rare, complications can occur after any type of surgery. Excessive bleeding from the wounds, infection & deep vein thrombosis are the most common complications. In addition, patients sometimes notice a small patch of numbness over the knee joint where the stab incisions were made. This tends to be self-limiting and slowly regresses with time. Finally with any tears where a portion of meniscus is removed, it is possible to get a recurrence of symptoms a couple of years later. This is because every effort is made to preserve as much meniscus as possible and thus minimise the development of arthritis in the future.
You should seek advice if the pain dramatically worsens a couple of days after surgery. Also call if the knee joint becomes more swollen or you get a significant amount of bleeding from the knee. Any symptoms such as calf swelling or tenderness or simply feeling unwell or shortness of breath should also be assessed.
Compiled October 2015
Review date: March 2016
Review date: March 2016