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.

ACL Reconstruction Candidates

The best candidates for ACL reconstruction surgery are younger patients who are either involved in high-demand sports or have an occupation which involves manual labor.

The best candidates for conservative (non-surgical) treatment are older or sedentary patients. We usually recommend a "wait-and-see" approach with them.

Things to discuss with your orthopaedic surgeon when deciding whether or not to have surgery:

• Long and short-term goals
• Age
• Willingness to change lifestyle
• What are your other responsibilities?
• Do you need the surgery?

In general, the people with the most demanding lifestyles will benefit from surgery. These include athletes involved in jumping and cutting sports and people involved in manual labor such as farmers and construction workers.

The natural history of an unhealed ACL is not well documented. However, most surgeons believe that if a knee is allowed to sublux or become loose because of torn ACL, damage may occur time. If this damage occurs at a young age and goes untreated, the patient may develop a diseased or arthritis knee at a young age.

Most orthopaedic surgeons agree that rehabilitation is enhanced by delaying surgery two to four weeks. Usually by that time your knee is not swollen and it has regained its range of motion. By waiting, you can also choose a surgery time that is convenient for you.

ACL Reconstruction Outcome & Benifits

Successful ACL reconstruction surgery tightens your knee and restores its stability. It also helps you avoid further injury and get back to playing sports.

ACL reconstruction has made significant progress in recent years. Complications that were common in the past, i.e. knee stiffness and graft failure, are still possible but less common today. The use of stronger grafts has increased the success rate to approximately 95 percent.

As with any surgery, the risk of joint infection and blood clots are still possible. However, with current techniques, the chances of these complications occurring should be significantly less than 1 percent.

Prepare for ACL Reconstruction

Prior to ACL reconstruction, you are placed on a physical therapy program to restore range of motion, decrease swelling, and strengthen the muscles around the knee joint.

You are also required to see your family doctor for a complete physical before undergoing surgery. Laboratory work is a routine part of pre-operative preparation as well.

You will be asked not to eat or drink for a period of time prior to surgery. Also, you will be instructed to arrive at the hospital early the day of surgery to allow for check-in and preparation.

Ankle Replacement Surgery Overview

A complete ACL tear will not heal with time. However, not everyone will need or benefit form surgery. The orthopaedic surgeon assesses each case individually and discusses with the patient their options.

The Anterior Cruciate Ligament (ACL) is a ligament in the center of your knee that becomes damaged when twisted too far, such as in a skiing injury.

ACL Reconstruction is performed using a combination of open surgery and arthroscopy.

Before the ACL reconstruction process begins, your surgeon will examine your knee arthroscopically, and repair any additional damage to the knee, such as a torn meniscus, or worn articular cartilage.

Reconstruction of the ACL begins with a small incision in your leg where small tunnels are drilled in the bone. Next your new ACL is brought through these tunnels, and then secured. As healing occurs, the bone tunnels fill in to secure the tendon.

There are three methods of creating a replacement ACL. The first uses the patellar tendon, which connects the patella to the tibia.

The middle third of the tendon and a small portion of bone on either end is harvested and used as the new ACL. This is called a patellar tendon autograft, because your own tissue is used.

Another autograft method uses the semitendinosus-gracilis (hamstring) tendons, which connect muscles in the back of the thigh to the lower leg. Two small portions of these tendons are harvested and removed through a small incision in your leg, then they are looped to form a strong new ACL.

The third method of creating a replacement ACL uses an allograft, meaning the tendon comes from a source other than your own body, such as a donated achilles tendon.

Anesthesia

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 Incision

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.

Surgical Steps

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.

Closing the Incisions

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.

ACL Reconstruction Recovery

Immediately after ACL reconstruction, you will be taken to a recovery room where your vital signs and general condition are observed. The knee will also be elevated and packed in ice to reduce swelling. Once the anesthetic wears off, a nurse will probably ask you to move your leg and perform some minor leg exercises to improve circulation and mobility.

Most ACL reconstruction patients will stay overnight for observation and pain control. However, some surgeries will be performed on an out-patient or a 23-hour observation basis. While under observation, you will be administered some form of pain control. Advanced pain control techniques such as the morphine pump and nerve blocks will be tailored to fit your needs. Once you return home, you will take prescribed medications to control inflammation and pain. Make sure to follow your doctor's instructions regarding dosage and interaction with other drugs.

To allow for healing of your incisions, avoid getting the incisions or bandages wet, and avoid bathing until you get the doctor's approval.

ACL Reconstruction After Care

When just your ACL is reconstructed you will use crutches for four to 10 days post-op. However, you will be allowed full weight-bearing as tolerated immediately following surgery. A brace that allows motion will be used for four weeks after surgery to protect the ACL graft. When your meniscus is torn significantly enough to be repaired at the time of your ACL reconstruction, more protection of the joint will be needed. Your time on crutches and the use of the brace will be adjusted accordingly.

Your rehabilitation program will begin the morning following surgery under the supervision of the orthopaedic surgeon and the physical therapist.

There are three main goals to be achieved following surgery:

1. Swelling control
2. Full knee extension (equal to opposite leg)
3. Muscle control

After you are discharged from the hospital, you will begin your out-patient physical therapy. This will include following a pre-established protocol which will help you regain strength, mobility, and agility in a progressive manner while protecting your knee.

When You Return Home

When you achieve good strength (70% or better compared to the opposite leg), you may be allowed to begin higher level activities such as jogging, swimming and bicycling.

Criteria for return to full competitive activities (sports) include:

1. Near normal strength
2. Full range of knee motion
3. No swelling
4. Good stability
5. Completion of functional program

A competitive team athlete can usually return to organized sports about four months post-operatively, while we recommend a recreational athlete wait approximately six months.

ACL Reconstruction Possible Risks

There are risks--be sure to discuss these with your doctor. There are risks associated with the graft. These include failure of the graft, loosening of the graft, and a chance that the graft does not provide optimal stabilization of the knee following ACL surgery. All of these may require a revision reconstructive surgery.

There are complications associated with ACL surgery that are risks of all surgical procedures. The most significant is the risk of infection. This is especially concerning in patients who receive a donor graft. Recently, there have been several reports of patient deaths because of infected donor grafts after ACL surgery. These cases have been addressed, and the provider of the graft has been shut down, but this is a potential risk with a donor graft. There are also risks of anesthesia. These should be discussed with the anesthesiologist before ACL surgery.

All that said, the chance of a successful ACL surgery is about 90%. It is important, however, that patients understand this is a big procedure. Most importantly, for the ACL surgery to have any chance of success, a significant effort is required post-operatively by the patient. Without adherence to a proper rehabilitation protocol, the ACL surgery failure rate increases dramatically!

This is also very important to consider. While no one dies because they don't have a good ACL, there may be a significant downside to not having ACL surgery. One important factor is quality of life. Many patients rely on certain activities to maintain their mental health. If an individual cannot find satisfaction without being able to participate in sports that require a function ligament, then ACL surgery is an option. Also, new studies have shown that degenerative (arthritic) changes in the knee may be accelerated in patients without an ACL. This means that every time the knee "gives out," you may be damaging the cartilage. This is especially important for younger patients who will need good knees for many years. Many surgeons recommend that if a young patient attempts non-operative treatment, and they have a repeat episode of instability (after the initial injury), then they should have the reconstructive surgery.

Risks for ACL repair surgery are:

• Joint Stiffness
• Lack of extension
• Failure of the graft
• Re-injury to the ACL
• Injury to other structures in the knee
• Blood clots
• Infection