Anterior cruciate ligament reconstruction, commonly known as ACL reconstruction, is the most common ligament reconstructive procedure. There is a 5-10% likelihood of any person rupturing their ACL at some point in their lives. Some people are more at risk than others, particularly those who play a sport which involves changing direction abruptly, such as netball or skiing.
Most people will experience episodes of instability and their impacted knee(s) giving way when changing direction after tearing their ACL. If ACL reconstruction is required, the procedure is performed via keyhole surgery and usually requires an overnight stay in hospital.
If you require ACL repair, contact Queensland Knee Surgery today. We have appointments available in the next 48 hours!
What is the Anterior Cruciate Ligament (ACL)?
The ACL is a cord of tissue in the middle of the knee connecting the thighbone (femur) and shinbone (tibia). It acts as a key stabiliser for rotation and change in direction activities. When it is torn or ruptured, it allows the knee to move abnormally, which results in an unsteady knee prone to giving way when changing direction, especially if trying to slow down at the same time.
The incidence of ACL ruptures in the general community is approximately 1 person in 20 or 5% of the population but some people are more at risk than others. The likelihood of rupturing your ACL is influenced by a number of variables, including your anatomy (size of ACL, bone structure surrounding the ACL, body mass) and activity level.
Symptoms of an ACL Injury
People often note that they hear or feel a ‘pop’ in their knee when they injure their ACL. Common symptoms of an ACL injury include:
- Loss of range of motion
- A ‘pop’ noise or sensation
- Severe pain
- Inability to continue activity
- Swelling and redness
- A feeling of instability
- The knee ‘giving way’ when weight is applied
If you are experiencing any of the above symptoms, it’s advisable to seek immediate medical care. The knee joint is very complex and it’s therefore important to get a prompt and accurate diagnosis to determine the severity of the injury and the best course of treatment.
Common Causes for ACL Injuries
Most ACL injuries occur during activities which can put stress on the knee. At risk activities include any sport or activity that involves:
- Changing direction whilst trying to slow down or stop (known as cutting)
- Stopping suddenly
- A direct blow to the knee, such as a collision
- Pivoting with your foot firmly planted
- Landing from a jump incorrectly
The most common sports which involve the above activities and therefore are at higher risk of an ACL injury include netball, touch football, skiing, basketball, soccer, football, tennis, volleyball and gymnastics.
Repeated episodes of the knee giving way over time puts the knee at risk for damage to the meniscal and articular cartilage, with increased risk of developing osteoarthritis.
How is an ACL Recontructed?
Reconstruction of the ACL is performed using a keyhole procedure, which is minimally invasive and benefits the patient in the following ways:
- Less pain
- Lower rates of complications during surgery
- Quicker postoperative recovery time
- Smaller incisions with smaller areas of scarring
- Easier progression toward regaining a full range of motion in the knee
The keyhole surgery involves creating three small incisions, two of which are made horizontally on the front of the knee and usually measure less than 1 cm each. The third incision is vertical and positioned on the inner-facing side of the lower part of the knee, usually measuring 3 cms or less.
The two horizontal incisions are used for the keyhole or arthroscopic instrumentation of the knee, while the vertical incision is used reconstruct the ACL. This is completed by removing spare hamstring tendons (gracilis and semitendinosis), taking special care to preserve and protect the attached muscles. Holes are drilled into the shinbone and thighbone before the tendon graft is anchored in the tunnels created. The replacement ACL tendon is then secured in place with titanium screws or cross pins.
Two small drains are positioned within the knee to allow for drainage of any bleeding, a temporary extension splint is fitted and patients are admitted to the hospital for an overnight stay.
What happens after ACL Surgery?
The day following surgery, the drains are removed and patients undergo an X-ray to confirm the positioning of the replacement ACL. Patients will usually have to use crutches for comfort for the first week or two. Most patients will be able to walk without crutches after two weeks, unless a torn meniscus was also repaired in the process. In this case, patients may need the aid of crutches for up to six weeks post-operation.
Patients are to immediately commence a self directed exercise schedule with intermittent physiotherapy supervision to help regain their strength and range of motion. They are usually able to recommence leg weights and gym activities within three months, running by four months, multi-directional drills by five months, sports drills by six months and return to sporting competition by the end of their sixth month of rehabilitation.
Most people are able to return to work within a week or two if their position is office based and three to four weeks if their job requires them to perform heavy manual duties. Once completing an ACL rehabilitation program, the likelihood of rupturing your reconstructed ACL is lower than the likelihood of injuring the ACL in your other knee. Patients should be able to resume all sporting and outdoor activities with confidence in time.
ACL Reconstruction & Knee Arthritis Treatment
On some occasions, patients will present with both an ACL deficiency and arthritis and will require consideration of both an ACL reconstruction and a high tibial osteotomy (HTO), which can be performed in a staged manner. In the case of staged treatment, the ACL reconstruction would be performed first and the HTO at least three months later.
The procedures can also be performed as a combined simultaneous surgery where both the ACL reconstruction and high tibial osteotomy are completed under the same anaesthetic. This is rarely necessary in patients that have suffered a recent ACL rupture, but usually in patients that injured their ACL many years ago.
ACL Reconstruction Combined with HTO
If the arthritis (pain, swelling, stiffness) is the major concern, more so than the ACL insufficiency (giving way), it may be appropriate to consider undergoing a HTO in preference to an ACL reconstruction. When a HTO is performed in this circumstance, a technique known as an opening wedge can position the plate in a way that it helps overcome the symptoms or arthritis, but also conveys some benefit to the instability symptoms of an ACL deficient knee (see Osteotomy).
Rehabilitation after ACL Reconstruction & HTO
If an ACL reconstruction is being contemplated along with a HTO, it is sensible to perform the ACL reconstruction before the HTO, regardless of whether it is performed on the same day or in a staged manner prior to the HTO. The rehabilitation following a combined ACL reconstruction and HTO is initially dictated by the rehabilitation for the HTO, with a slower return to weight bearing and knee bending. Combining the procedures usually adds two months to the overall rehabilitation period that would be followed for an ACL reconstruction in isolation. Including the two extra months of rehabilitation time with both procedures, the following is a guide for expected timelines:
- Leg weights at five months
- Straight line jogging at six to seven months
- Multidirectional running at seven to eight months
- General sport at eight to nine months
Get back on track and return to the sport and activities you love by contacting Queensland Knee Surgery for an ACL reconstruction and/or HTO. Organise a consultation today and get fast, professional advice on the best options for you! You can have full confidence in the service we provide as we a dedicated knee-only practice with more than 20 years of orthopaedic surgery experience.
For expert advice and/or to organise repair of your ACL tear or injury, request an appointment below.