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ACL Reconstruction

Introduction

The Anterior Cruciate Ligament (ACL) is an essential stabilising ligament in the knee. When the ACL is torn, it doesn’t heal naturally, often resulting in knee instability.

Fortunately, ACL reconstruction is a commonly performed surgery to restore stability to the knee. Many of these surgeries are now performed arthroscopically using minimally invasive techniques, which result in smaller incisions and faster recovery times.

For adult patients, both traditional ACL reconstruction surgery and All-Inside ACL reconstruction surgery involve replacing the torn ACL with a tendon graft, such as a hamstring, quadriceps, or cadaver tendon graft. This graft acts as a substitute for the damaged ligament, promoting knee stability.

Indications and Contraindications

Indications for ACL Reconstruction Procedure:

  • Anterior Cruciate Ligament (ACL) Injury: The primary indication for ACL reconstruction is a significant tear or rupture of the ACL, which typically occurs during sports-related activities, leading to instability, pain, and functional limitations in the knee.
  • Young, Active Patients: ACL reconstruction is often recommended for young, active individuals who wish to return to sports or physically demanding activities that require a stable knee joint.
  • Meniscus or Cartilage Damage: When the ACL injury is accompanied by damage to the meniscus or articular cartilage within the knee joint, ACL reconstruction may be indicated to address these associated problems.
  • Knee Instability: If the patient experiences knee instability, recurrent giving way, or the sensation of a wobbly knee, ACL reconstruction can help restore joint stability.

Contraindications for ACL Reconstruction Procedure:

  • Inadequate Rehabilitation Potential: Patients with limited potential for rehabilitation, such as those with severe comorbidities, may not be suitable candidates for ACL reconstruction.
  • Low Demand for Knee Stability: Some patients with ACL injuries may not engage in activities that require a stable knee joint, making ACL reconstruction less necessary.
  • Patient Preference: In cases where the patient prefers conservative management and can adapt their activities to accommodate knee instability, surgery may not be the preferred option.
  • Medical Unfitness: Patients with underlying medical conditions that make surgery high-risk, such as severe heart or lung disease, may not be ideal candidates for ACL reconstruction.
  • Unrealistic Expectations: Patients with unrealistic expectations regarding the outcomes of the procedure may not be suitable candidates if their expectations cannot be managed or met.

The decision to undergo ACL reconstruction should be made after a thorough evaluation by a healthcare professional, considering the individual patient’s specific medical history, condition, lifestyle, and overall health.

Benefits and Risks

Benefits of ACL Reconstruction Procedure:

  • Improved Knee Stability: ACL reconstruction helps restore stability to the knee joint, reducing the risk of recurrent episodes of instability or giving way.
  • Pain Reduction: The procedure often alleviates pain and discomfort associated with ACL injuries, allowing for improved knee function.
  • Functional Recovery: Patients can regain the ability to participate in sports and physical activities that demand a stable knee joint, contributing to an improved quality of life.
  • Prevention of Secondary Injuries: ACL reconstruction can reduce the risk of secondary injuries, such as meniscus or cartilage damage, which may occur due to ongoing knee instability.
  • Long-Term Joint Health: ACL reconstruction can help protect the long-term health of the knee joint, potentially reducing the risk of degenerative changes and osteoarthritis.

Risks of ACL Reconstruction Procedure:

  • Infection: There is a risk of post-operative infection, although it’s relatively low when proper aseptic techniques are followed.
  • Graft Failure: The graft used to reconstruct the ACL may fail to integrate properly or may be re-injured, requiring additional surgery.
  • Limited Range of Motion: Some patients may experience a temporary or permanent limitation in knee joint range of motion following surgery.
  • Nerve or Blood Vessel Damage: Injury to nearby nerves or blood vessels during surgery is a potential risk, although it is relatively rare.
  • Complications from Anesthesia: As with any surgical procedure, there are potential risks associated with anesthesia, including allergic reactions or adverse effects.
  • Rehabilitation Challenges: Post-operative rehabilitation is crucial, and non-compliance or inadequate rehabilitation can lead to suboptimal outcomes.
  • Persistent Instability: In some cases, ACL reconstruction may not eliminate knee instability, or it may recur due to various factors.

Treatment Options

Not everyone with an ACL injury will require surgery. Treatment options vary depending on the patient’s age and activity level:
  • Conservative Management: For older, less active patients, conservative and non-surgical approaches can be effective. Strengthening exercises or a brace can provide support and compensate for the injured ligament.
  • Reconstruction Surgery: Young and active patients with an ACL rupture typically benefit from reconstruction surgery. This procedure protects the menisci and promotes long-term knee stability.

Surgery becomes necessary when the patient finds it challenging to maintain their current knee stability and desires an active lifestyle.

Surgical Approaches for ACL Reconstruction Surgery:

Over the past ten years, surgical techniques for ACL reconstruction have significantly improved. Complications are now less frequent, and recovery times have become much quicker than in the past. ACL reconstruction surgery is typically performed arthroscopically. Professor Munjed Al Muderis is skilled in a minimally invasive alternative to traditional ACL reconstruction surgery known as All-Inside ACL Reconstruction. Both traditional ACL reconstruction surgery and All-Inside ACL reconstruction surgery involve replacing the damaged ACL with a tendon graft. The ruptured ligament is removed, and the bone is prepared to accept the new graft, which acts as a replacement for the old ACL. Different options for the tendon graft are available, each with their own advantages and disadvantages, which are shown below. In traditional ACL surgery, a tunnel is drilled from the outer tibial cortex into the knee joint for graft insertion, which can cause post-surgery pain. However, All-Inside ACL reconstruction does not involve creating a tibial tunnel. Instead, a specialised tool called a reamer is used to create a tibial socket without violating the tibial cortex. All-Inside ACL surgery requires only three to four small arthroscopy incisions and offers benefits like less pain, faster recovery, and potentially more anatomical ACL reconstruction.

Types of Grafts:

Several different surgical options can be used for ACL reconstruction, including autologous hamstring or patellar tendon grafts, cadaveric donor grafts, and synthetic grafts (LARS). Each method has its own advantages and disadvantages, and the best option depends on the individual patient and their specific injury. Once the graft type is chosen, it is prepared to take the form of a new tendon and is passed through into the bone. Various devices are used to fix the new tendon into place, supporting the ligament’s healing into the bone, which typically takes about six months.

All-Inside ACL Reconstruction

All-Inside ACL Reconstruction is an innovative, minimally invasive alternative to traditional ACL reconstruction surgery. This advanced technique offers numerous benefits over conventional methods, including quicker recovery times and reduced post-operative discomfort.

Advantages of All-Inside ACL Surgery:

  • Less pain following surgery compared with traditional techniques.
  • Small incisions and less scarring contribute to a better cosmetic outcome.
  • A faster recovery allows patients to return to daily activities sooner.
  • A quicker healing time promotes a faster overall recovery process.
  • The specialised instrumentation used in All-Inside ACL Reconstruction allows for a more anatomic ACL reconstruction.

It’s worth mentioning that All-Inside ACL reconstruction is a technically challenging procedure. Patients can take comfort in knowing that Professor Munjed Al Muderis brings extensive experience and proficiency to this surgery.

For individuals contemplating ACL reconstruction, discussing the possibility of All-Inside ACL reconstruction with their doctor is advisable. This innovative approach offers a smoother recovery and a faster return to an active lifestyle.

ACL Reconstruction with Additional Meniscal Repair

Meniscal Repair Surgery:

Repairing a torn meniscus is a precise procedure that demands meticulous care until complete healing is achieved. The approach taken depends on the specific nature of the injury and may include suturing the tear, knee arthroscopy, or partial meniscectomy. These procedures may be combined with traditional ACL reconstructive surgery.

Postoperative Precautions:
  • ACL rehabilitation will be adjusted to protect the meniscal repair.
  • Weight-bearing mobilisation is allowed as tolerated, supported by crutches for the first six weeks.
  • Avoid knee flexion beyond 90 degrees during the first six weeks and ensure the knee is extended during the stance phase of walking.
  • Refrain from resisted quadriceps exercises until six weeks post-surgery.
  • Avoid deep knee squats and leg presses beyond 90 degrees of knee flexion for three months.
  • All other instructions are similar to the standard ACL protocol and post-surgery recovery.

ACL Reconstruction using synthetic LARS Ligaments

LARS (Ligament Augmentation and Reconstruction System) ligaments are innovative artificial ligaments used for the reconstruction of ruptured ligaments, either intra-articular or extra-articular.

Advantages of LARS:

  • An earlier return to work, depending on the individual’s activity level and individual recovery time.
  • An earlier return to competitive training.
  • An earlier return to full-contact sports once the sense of motion and muscle strength has completely returned.
  • A shorter surgical procedure.

Utilising LARS ligaments significantly reduces surgery time as there is no need for additional graft harvesting. As a result, patients can anticipate a quicker return to full function compared to ACL reconstruction using hamstring or patella tendon grafts. The advantage of LARS ligaments lies in their ability to promote healing of the original ligament tissues without the need for traction.

Pre-Surgery Information

Prior to ACL Reconstruction surgery, the following procedures and preparations will take place:

  1. Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
  2. Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
  3. Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.  
  4. Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
  5. Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
  6. Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

  • Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
  • A hospital gown will be given, and the operation site will be shaved and cleaned.
  • Betadine skin prep will be applied to the area above the operation site and wrapped.
  • All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

ACL (Anterior Cruciate Ligament) reconstruction surgery is a procedure designed to replace a torn or ruptured ACL in the knee. Here’s an overview of the surgical approach:

  1. Preparation: The patient is positioned on the operating table, and the surgical team cleans and sterilizes the surgical site.

  2. Anesthesia: General or regional anesthesia is administered to ensure the patient is pain-free and unconscious during the procedure.

  3. Incisions: Small incisions are made around the knee joint. These serve as access points for arthroscopic instruments, allowing the surgeon to visualize the knee’s interior.

  4. Arthroscopy: An arthroscope, a small, tube-like camera, is inserted through one of the incisions. This provides a clear view of the joint’s interior, including the torn ACL.

  5. Graft Harvest: If an autograft is being used, typically a portion of the patient’s own hamstring, patellar tendon, or quadriceps tendon is harvested through a separate incision. Alternatively, an allograft (donor tissue) may be used.

  6. Tunnel Creation: The surgeon drills small tunnels in the tibia and femur to place the graft. These tunnels serve as anchor points for the new ACL.

  7. Graft Fixation: The graft is threaded through the tunnels and secured in place using screws or other fixation devices.

  8. Closure: The incisions are closed with sutures or staples, and dressings are applied.

  9. Recovery: The patient is moved to the recovery room, where they begin the process of awakening from anesthesia.

Duration: The entire surgical procedure typically takes between one and two hours, ensuring a faster and smoother recovery.

ACL reconstruction is often performed as an outpatient procedure, allowing patients to return home the same day or following a short hospital stay. Post-operative rehabilitation and physical therapy are essential components of the recovery process to optimize knee function and stability. Patients typically regain their mobility gradually over several months.

Post-Surgery Information

Immediate Post-Surgery:

Upon discharge, the medical team will remove the large outer dressing, leaving a waterproof dressing in place. Additionally, they may apply a tube-grip bandage for added support.

Whether or not a brace or immobilisation is necessary following surgery will be determined by your surgeon’s recommendation, as individual cases may vary.

To reduce swelling, patients should apply ice regularly for 20-minute intervals until the swelling subsides.

Follow-Up: Regular follow-up appointments with the team will help monitor your progress and address any concerns:

  • 1 week postop: for wound check,
  • 2 weeks postop: for sutures removal.
  • 6 weeks postop: for x-ray assessment of healing progressing,
  • Later at 3, 6, 9, 12 months postop and further annually an x-ray will be mandatory.
  • A control MRI will also be needed to assess the reconstructed ligament

 

Physiotherapy should begin between two and five days after surgery, with the goal of achieving a quick return to a full range of motion and strengthening the quadriceps and hamstring muscles.

The Recovery Process:

Range of motion:

  • Patients should engage in passive and active range of motion exercises to ensure full extension is achieved and maintained within one week after surgery. The goal is to reach 90 degrees of flexion by week two, with progression to full flexion as tolerated.

Weight-bearing status

  • Initially, weight bearing can be done as tolerated, using crutches. The use of crutches can be discontinued when the patient can achieve full knee extension without an extensor lag and can walk comfortably without a flexed knee gait pattern, following the guidance of their healthcare team.

Muscle rehabilitation:

  • Immediately post-operatively, static quadriceps and co-contraction exercises should be performed.
  • Closed-kinetic chain exercises are advised for the first two to three months, as prescribed by the physiotherapist.
  • The patient may start cycling on an exercise bike, swimming, and doing leg presses, but only if recommended by their healthcare provider.
  • Proprioception training can begin four weeks after surgery.

Sports:

Returning to full activity should be approached with caution to avoid overexertion and stress on the knee. 

  • Once the swelling settles, the patient can start cycling on a stationary exercise bike.
  • Low-impact exercises like swimming can begin after two weeks.
  • After six weeks, jogging can be initiated.
  • A return to sport-specific training is recommended between 12 and 16 weeks, when quadriceps strength is back to at least 80%.
  • A full return to sports is possible when quadriceps strength reaches at least 90% and sport-specific skills can be performed without symptoms.

It is crucial for patients to diligently follow the instructions of the medical team and physiotherapist to ensure a successful recovery and a safe return to an active lifestyle.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000

This treatment could be eligible for our No 'Out-of-Pocket' Expenses Program

For further information, click here or to check your eligibility, please contact our team. 

Call on +61 2 8882 9011

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Professor Munjed Al Muderis

Professor Munjed Al Muderis is an orthopaedic surgeon and a clinical professor at Macquarie University and The Australian School Of Advanced Medicine. He specialises in hip, knee, trauma and osseointegration surgery. He is a fellow of the Royal Australasian College of Surgeons and Chairman of the Osseointegration Group of Australia.

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Disclaimer

Information provided via this website is for educational and communication purposes only. The material presented is neither intended to convey the only, nor necessarily the best, method or procedure, but rather represents techniques and procedures used by Professor Munjed Al Muderis. Professor Munjed Al Muderis disclaims any and all liability for injury and/or other damages which result from an individual using techniques presented on this website. Professor Munjed Al Muderis, to the best of his knowledge, believes the information presented is current and applicable to work being done by orthopaedic surgeons worldwide.