ACL Reconstruction

Anterior Cruciate Ligament (ACL) Anatomy

The ACL is a strong rope like structure located in the center of the knee. It crosses from the back of your femur (thighbone) and runs down to the front of your tibia (shinbone).

The function of the ACL is to provide stability to the knee.

Causes of ACL Injuries

ACL injuries are one of the most common ligament injuries that occur. Once the ACL is torn it has a poor ability to heal and typically will not heal if untreated.

Causes of ACL injuries are usually when a patient either

  • Twists the knee too far, or
  • There is a sudden change in direction or speed

Symptoms of an ACL Injury

Patients report the following associated symptoms of anterior cruciate ligament injuries:

  • An audible ‘pop’ sound from the knee
  • A sensation of something tearing inside the knee.
  • A feeling as if the knee has momentarily ‘come out of its joint’.

These symptoms are usually followed by:

  • Swelling of the knee
  • Difficulty walking and
  • Pain

ACL injuries typically cause instability of the knee

  • On uneven ground or
  • During sport when a patient attempts a ‘sidestep’ or ‘twist’ manoeuvre.

ACL Injury Diagnosis

Dr Biggs will need to diagnose the specific nature of the ACL Injury or the extent of any associated injury in the knee joint

Often, an ACL Injury can be identified during a physical exam by a medical professional. By manipulating the knee and leg bones the cause of symptoms can be pinpointed.

During this consultation Dr Biggs will:

  • Take a medical history
  • Perform a physical examination
  • Assess the joint’s range of motion

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Imaging Tests

  • X-rays do not show cartilage and ligaments. They can help rule out other problems with the knee that may have similar symptoms like fractures (broken bone) .
  • MRI can create detailed images of both hard and soft tissues within your knee. An MRI can produce cross-sectional images of internal structures required if the diagnosis is unclear or if other soft tissue injuries are suspected such meniscal or articular cartilage injuries.

While not all of these tests are required to confirm the diagnosis, this diagnostic process will also allow Dr Biggs to review any possible risks or existing conditions that could interfere with the surgery or its outcome.

Untreated Anterior Cruciate Ligament Injuries

When this ligament tears, unfortunately it doesn't heal and often leads to a feeling of instability in the knee.

If untreated, additional ligament problems are more likely to develop for both active adults and children. A significant number of patients with an untreated (unreconstructed) ACL tear have recurrent:

  • Knee instability
  • Buckling of the knee
  • Giving-way of the knee

These recurrences must be avoided as these episodes cause further problems like cartilage tears and premature wear and tear resulting in arthritis of the knee.

Giving Up Sport Option

Where a patient is considering giving up sport to avoid an ACL Reconstruction operation, a physiotherapy programme may provide sufficient stability for daily living.

Active Patients Option

It is generally agreed that active patients unwilling to cease sporting activities have little choice but to consider surgical reconstruction.

An ACL Reconstruction is the best chance to stabilize the knee and continue a sport or recreational activity.

ACL Reconstruction Surgery

ACL Reconstruction Surgery

The procedure for anterior cruciate ligament reconstruction replaces a patient’s torn anterior cruciate ligament (ACL) tendon with a new tendon to restore knee stability.

The surgery involves:

  • Removal of the affected tendon
  • Drilling a hole into the tibia (shin bone)
  • Drilling a second hole the femur (thigh bone)
  • Anchoring the replacement tendon in the tunnels created within the bones
  • Securing the replacement ACL tendon with screws or cross pins

Benefits of Arthroscopic Method

Dr Biggs uses a minimally invasive arthroscopic approach to ACL reconstruction. This approach is a very common surgical procedure.

By performing ACL reconstruction surgery using the advanced arthroscopic approach and a tiny camera (arthroscope), patients benefit by:

  • Smaller incisions with little scarring
  • Less pain and lower complication rates
  • Quicker postoperative recovery, and
  • Easier progression toward regaining full knee movement

Using this method also enables Dr Biggs to examine the knee structures (including the cartilages) within your knee and where necessary treat these structures (if necessary) at the same time

Cross-section of ACL graft

Graft Options for ACL Surgery:

Autograft

Your own tendon "autograft" is taken from the knee and transplanted to replace the torn ACL. Hamstring tendon (from the inner side of your knee) or patellar tendon (from the front of your knee) are the most commonly used autografts.

Autograft ACL reconstruction is indicated in the young active population.

Recovery is 6-9 months.

Autograft Hybrid:

If the diameter of the graft is <7mm we know that the re-rupture rate is higher. In that case the graft can be increased in size and strength by adding a synthetic (Lars) ligament or allograft) (donated frozen tendon). This decision is often only made at the time of surgery. Autograft hybrid graft is suitable for all ages.

Recovery is 4-6 months.

Allograft Hybrid:

This graft is ideally suited for patients > 40 years whose sporting aspirations are moderate. No tendon is taken from your knee so the recovery is much quicker.

A synthetic (Lars) ligament is used to reinforce the allograft tendon.

Recovery is 3-4 months.

Synthetic (Lars) Ligament:

This is indicated when the surgery is performed within 3 weeks of injury and when there is a viable tendon stump. The ACL is repaired rather than replaced. Pre-operative MRI scan gives a good indication whether this procedure can be performed. The final decision is made at the time of surgery.

This procedure is suitable for patients >30 years of age who require rapid rehabilitation. No tendon is taken from your knee so the recovery is much quicker.

Recovery time is 8-12 weeks.

Postoperative Benefits for LARS ACL Reconstruction

Unlike with a ‘reconstructed’ ACL, the repaired ACL using LARS does not go through a period of graft weakness. While recovery time is normally quick recovery still requires the limits below:

  • Running is best avoided until most of the knee swelling has dissipated.
  • Sport specific activities, such as side-stepping, jumping and cutting should wait until there is adequate quads and hamstring strength (within 90% of the uninjured limb).
  • Return to unrestricted sporting and recreational activities are allowed when the knee has regained 90% strength and motion.

Anterior Cruciate Ligament Injuries Post-op patient information - Patient Info Handouts

Anterior Cruciate Ligament Injuries Post-op patient information Anterior Cruciate Ligament Injuries Post-op patient information

Anterior Cruciate Ligament Injuries Post-op patient information Click here to download the PDF

Preparations Prior to ACL Surgery

Once Dr Biggs decides that surgery is required, preparation is necessary to achieve the best results and a quick and problem free recovery.

Preparing mentally and physically for surgery is an important step toward a successful result.

  • Dr Biggs will create a treatment plan and
  • Patients will also need to understand the process and their role in it

Dr Biggs will also need to:

  • Discuss any medications being taken with your doctor or physician to see which ones should be stopped before surgery. You should stop taking aspirin, warfarin, anti-inflammatory medications or drugs that increase the risk of bleeding one week before surgery to minimise bleeding
  • Review blood replacement options (including banking blood) with your doctor
  • Consider alternate medical interventions and other treatments
  • Eat a well-balanced diet, supplemented by a daily multivitamin with iron.
  • Consider losing weight (if overweight) before surgery to help decrease the stress on the new joint. However, dieting one month before surgery.
  • Stop or cut down smoking to reduce your surgery risks and improve your recovery
  • Treat any tooth, gum, bladder or bowel problems before surgery to reduce the risk of infection

Report any infections to Dr Biggs prior to surgery as the procedure cannot be performed until all infections have cleared up.

Anterior Cruciate Ligament Injuries Pre-op patient information - Patient Info Handouts

Exercise Preparation

To help prepare you for the surgery a preoperative physiotherapist appointment is required to:

  • Fit crutches (which should be brought to hospital)
  • Instruction on partial weight-bearing crutches useage
  • Learning how to reduce inflammation (icing of the knees), and
  • Learn postoperative exercise (co contractions, leg lifts with the knee extended, etc).

Risks of Knee Surgery

As with any major operation, orthopaedic surgery has potential risks and complications. Surgical complications may include:

  • Infection
  • Stiffness of the knee
  • Rerupture of the graft.
  • Bleeding
  • Blood clots
  • Damage to local tissue

Dr Biggs will discuss any concerns you may have before any procedure.

Day Surgery

If you are having Day Surgery, remember the following:

  • Arrange for someone to take you home, no driving is recommended for at least 24 hours
  • Do not drink or eat anything in the car on the trip home as the combination of anaesthesia, food, and car motion can cause nausea or vomiting.
  • Wait until you are hungry before trying to eat.
  • Begin with light meals and avoid greasy food for the first 24 hours

After Your Operation

After your operation you will have a drip in your arm for pain medication and antibiotics.

You may need one night in hospital, although it is possible to leave hospital the day of surgery.

The initial replaced ACL’s fixation strength will be sufficient to allow early movement and exercise. Splints are not usually necessary.

Crutches are required for 1 – 2 weeks following the reconstruction. Once you are off crutches, you can begin driving.

If any postoperative problems arise with your knee, such as redness, increasing pain or fevers, do not hesitate to contact Dr Biggs. If unavailable, seek advice from the hospital or your doctor.

Return to Work

You may return to light work duties after 1 week. You will not be fit to perform work duties that involve:

  • Prolonged standing
  • Heavy lifting
  • Bending or
  • Excessive stair climbing

for a minimum of 4 – 6 weeks.

Postoperative Recovery Plan

Following ACL autograft (Hamstring) reconstruction.

Recovery from Knee Surgery will usually take about 12 weeks.

The physiotherapist will prepare an exercise programme. Much of the exercise programme can be done at home or at a gym, under your physiotherapist’s guidance.

Panadeine Forte or di-gesic tablets is all that is required for pain management for the first 5-7 days. Thereafter, regular over the counter Panadeine should be enough to control the pain (especially at night).

Week 1:

  • Ice your knee as directed by your physiotherapist
  • Full extension (make sure your knee comes out straight)
  • Full weight-bearing, wean off crutches
  • Quads and hamstrings co-contractions
  • Straight leg raises
  • Ankle range of motion (ROM) exercises

If unsure about the exercise program after leaving hospital, a physiotherapist appointment will be required..

Week 2 – 6:

The first postoperative appointment with Dr Biggs is needed 7 – 14 days following surgery. A postoperative knee X-Ray is required prior to to this review appointment.

  • Full weight-bearing – no limp – gait training
  • Ice before and after exercise till swelling has dissipated.
  • Isometric quad exercise
  • Isokinetic closed chain exercises.
  • Step work, leg press, squats
  • Active knee flexion and extension
  • Stationary bike
  • Swimming – no restriction
  • 21 days commence proprioception

Weeks 6 - 12:

The ends of the new graft will heal into the newly created bony tunnels over 6-12 weeks.

It is believed that the graft is at its weakest at 8 weeks post surgery, so care must be taken at this stage despite the fact that the knee will feel quite good.

During this period the strength of the new graft actually decreases. This is due to the new blood supply into the graft removing some of the main structural fibres from it.

An appointment with Dr Biggs should be made at 6 weeks post surgery, with an X-Ray of your knee.

An early return to exercise and sport is possible once the wounds have healed and the swelling in the knee has settled. The graft is strong enough to allow unlimited movement of the knee and immediate full weight bearing

Commence running

  • Progressive training
  • Step work, leg press, squats
  • Sport specific drills

Return to sport when you have regained 90% strength and motion of the knee.

After Week 12

Following this period the graft will gradually increase in strength as new structural fibres are laid down. The results of ACL Reconstruction surgery are good in ~ 95% of cases.

Recovery from knee surgery can be a slow process

  • By 6 months the knee is usually strong enough to resume all sports.
  • By 12-18 months recovery is normally fully completed.
  • There is no restriction to range of motion
  • No bracing required

Out of Town Patients

For out of town patients an appointment with a local doctor or physiotherapist 7 – 10 days post surgery for a wound check and the removal of sutures.

An appointment with Dr Biggs should be made at least 6 weeks post surgery, with an X-Ray of your knee.

Need to add and to differentiate post operative treatment programme for ACL Lars reconstruction

this should be tied to the 4th graft option - lars surgery

Post – Surgery

The following is a guide to the rehabilitation program following a Lars ACL repair.

The repaired ACL is protected by the Lars ligament

Unlike with a ‘reconstructed’ ACL, the repaired ACL does not go through a period of graft weakness.

Running is best avoided until most of the knee swelling has dissipated.

Sport specific activities, such as side-stepping, jumping and cutting should wait until there is adequate quads and hamstring strength (within 90% of the uninjured limb).

Return to unrestricted sporting and recreational activities are allowed when the knee has regained 90% strength and motion.

This usually takes ~ 12 weeks

Week 1:

  1. Ice your knee as directed by your physiotherapist
  2. Full extension (make sure your knee comes out straight)
  3. Full wt-bearing, wean off crutches
  4. Quads and hamstrings co-contractions
  5. Straight leg raises
  6. Ankle ROM (range of motion) exercises

Week 2 – 6:

  1. Full wt-bearing – no limp – gait training
  2. Ice before and after exercise till swelling has dissipated.
  3. Isometric quad exercise
  4. Isokinetic closed chain exercises.
  5. Step work, leg press, squats
  6. Active knee flexion and extension
  7. Stationary bike
  8. Swimming – no restriction
  9. 21 days commence proprioception

Weeks 6 - 12:

  1. Commence running
  2. Progressive training
  3. Step work, leg press, squats
  4. Proprioception
  5. Sport specific drills

Return to sport when you have regained 90% strength and motion of the knee.

 
  • Australian Orthopaedic Association
  • Royal Australasian College of Surgeons
  • Cronulla-Sutherland Sharks
  • NSW Swifts
  • Sydney Swans
  • South Sydney Rabbitohs