Knee Reconstruction (ACL) Surgery
What is ACL (Knee Reconstruction) Surgery?
ACL surgery aims to restore stability to the knee, and get back to playing sport while avoiding more knee damage.
Which Patients are Most Likely to Benefit from ACL Surgery?
Patients most likely to benefit from knee reconstruction surgery include:
- Young patients who wish to remain active.
- Your sport involves twisting, pivoting or rapid stopping.
- Your knee gives way (or feels like it might do so).
- You have a very physical job, or one where if your knee gave way it could be dangerous (eg builders or roof tilers).
When Should Surgery Be Performed?
Timing of surgery is important. If an ACL reconstruction is carried out too quickly it can lead to a worse result, because operating on a stiff and swollen knee can lead to long-term stiffness. It is therefore vital that you work with our rehabilitation specialist and your physiotherapist to regain as full and painless range of knee motion before. In some cases it is advisable to operate on the knee for other injuries, like a meniscal tear, first to allow you to rehab your knee properly and have the ACL reconstruction surgery weeks later when the knee is ready.
At Precision Integrated Orthopaedics, we place great emphasis on your preparation for surgery- also known as prehabilitation- extremely seriously in order to ensure that you get the best result. Prehabilitation involves physical preconditioning (coordinated by our rehabilitation physician, in conjunction with your physiotherapist and/or exercise physiologist), psychologically preparation (with our psychologists, where necessary), and safe management of your medications and pain (with the help of our pain specialists) to get you into the optimal shape for surgery.
The ACL Reconstruction Surgical Procedure
You will arrive at the hospital 1-2 hours before your surgery, having fasted (not eaten or drank anything) leading up to that. Most patients can go home on that same day. Your anaesthetist will give you a general anaesthetic (put you to sleep) for the procedure, and may also inject some local anaesthetic around some nerves (nerve block) to reduce pain when you wake up.
The first part of the procedure is harvesting the graft material.Graft options are patient’s own hamstring tendon, quadriceps tendon, patellar tendon, or may be a cadaver graft (allograft) or artificial (synthetic) graft. Once the graft is removed, it is prepared to ensure it is the correct shape and size for your knee.
Your orthopaedic surgeon then makes 2or 3 small incisions (1cm or less) at the front of the knee and fills the joint with sterile salty water (saline).
The arthroscope (like a surgical telescope) is then inserted into the knee so the surgeon can assess the damage and carry out the reconstruction. The surgeon then drills small tunnels into the femur and tibia bones, and the graft is passed through these tunnels. The graft is then fixed at either end with screws, buttons or staples. The incisions are closed with dissolvable sutures, and may also be glued to provide a strong waterproof closure.
Patients generally experience mild discomfort after waking up from an ACL reconstruction. Painkillers are typically required for only a short period.
You will be given crutches to use before leaving hospital- this is mainly for your safety, as most patients can put their weight through the leg immediately after surgery and are permitted bend the knee as much as their pain allows. Most people can walking comfortably by 2 weeks after surgery.
A brace is used to restrict bending in certain cases, usually only when there has been associated meniscal repair or more complex reconstruction. When prescribed, a brace is generally will be worn for around 6 weeks in total.
You will be given detailed information about your dressings and wound care. It is common for some of fluid injected into the knee to ooze out into the dressings over the first two days, and this typically has a faint red colour to it. You can shower with the waterproof dressings but avoid soaking in the bath or a pool. If they come loose or get soaked, please replace them with fresh waterproof dressings.
Your first post-operative visit will be with your orthopaedic surgeon at around 2 weeks. This appointment is critical for checking your wound healing. Further follow up with your surgeon with x-rays at each visit will be undertaken until the full healing has occurred.
At Precision Integrated Orthopaedics, we recommend that you book your first post operative appointment with your physiotherapist as soon as you have a confirmed surgical date. This should be between 2 and 5 days from the surgery. We will have communicate the rehab plan with your treating physiotherapist and/or exercise physiologist, and you will also see our rehabilitation physician pre-and post-operatively. The goals of rehabilitation are to manage swelling and stiffness, and then to concentrate on leg strength and function.
Your knee may remain swollen for up to 6 weeks after surgery. Recovery to the point where the knee feels relatively normal for most daily activities takes around 6 months.
Returning to driving takes at least 6 weeks for right knee surgery, and 2 weeks for left knee surgery (in an automatic vehicle; longer in manual vehicles where a clutch is being operated). Irrespective, you must be able to safely perform an “emergency stop” and you also must have stopped all painkilling medication other than over the counter meds such as paracetamol or anti-inflammatories before you can return to driving. Before you do return to driving, it is critical that you get final clearance from your rehabilitation specialist.
Return to work depends on your job. Office workers can usually return to work after 1-2 weeks, however heavy manual workers may need 2-3 months before resuming full duties.
Most patients will substantially recover from a torn ACL after six months, but depending on the extent of the injury and the type of graft, full recovery can take several more months. If the graft is taken from another tissue in the patient’s knee, the patient should be able to resume athletic activities in around six months. If the graft is from another person. completely recovery takes around nine months, as the foreign tissue takes longer to become attached to the bone.
Return to play depends on the type of sport. Returning to higher risk sports such as netball, soccer, football and basketball takes at least 9-12 months, and involves commitment to your rehabilitation program. Returning to sport too early will increase the risk of the graft failing.
ACL reconstruction surgery is generally a relatively safe procedure; however all types of joint surgery carry risks. The most common side effect is temporary pain and bruising. Other complications can include:
- Blood clots in the leg (deep venous thrombosis, or DVT), with swelling, pain and sometimes pulmonary emboli (blood clots travelling to the lungs, which may be life-threatening). You may require blood thinners for several months. DVT is uncommon after ACL surgery.
- Pain or discomfort around the hamstring or patella tendon graft site.
- This is very uncommon after ACL surgery. If the infection spreads into the knee joint itself, further surgery be needed to wash the joint out.
- Skin numbness around the knee.
- Joint stiffness. This usually settles within the first few days to weeks, however some patients suffer from excessive internal scarring called arthrofibrosis, which can lead to long-term stiffness.
- Rupture of the graft. The reconstructed AC ligament is at a higher risk of rupture during the first 3 months of rehabilitation (while it is regaining a blood supply). The risk is 1-2%, higher if returning to high impact sports. If this occurs, it can be reconstructed again using another graft.
- Anaesthetic risks.
- Allergic reaction to medications.
- Heart damage.
- Stroke and mortality (death).