Guide to ACL Reconstruction

At The Orthopaedic Clinic, we are genuinely concerned that our patients have a full understanding of their injury, treatment options, and the rehabilitation required for  recovery.  This handout is meant to complement the information you receive during your visit with Dr. Wilson.  We encourage you to read this and to ask questions.

The Orthopaedic Clinic is the leading regional center of excellence for sports medicine.  Dr. Wilson is fellowship trained in the latest sports medicine injuries and procedures.  Utilizing state-of-the-art diagnostic and treatment techniques, we offer a wide variety of conservative and surgical options for the patient with a torn anterior cruciate ligament.  Dr. Wilson has extensive experience in reconstruction of the anterior cruciate ligament.

ACL ReconstructionWhat is the Anterior Cruciate Ligament (ACL)?

The anterior cruciate ligament (ACL) is the central stabilizing ligament of the knee.  Running through the knee from the front of the tibia (shin bone) to the back of the femur (thigh bone) it assists proper movement of the joint and prevents abnormal slippage of the bones.  Abnormal slippage can create an unstable knee that “gives way” during activity.

How is the ACL injured?

While the ligament can be injured with a direct blow to the knee, it is more common to tear the ligament when pivoting or twisting on a planted food or by hyper extending the knee.

How do I know my ACL is torn?

Usually, a tear to the ACL results in sudden pain, giving way of the knee, or a combination of both.  Many patients report having heard a “pop” when they injured their knee.   The knee usually swells within 1-3 hours of the injury.  A doctor can examine the knee and is usually able to identify any ligaments that are injured.  The knee will feel loose and/or you will have muscle guarding during the examination.

Do I need x-rays, MRI’s or any other tests?

A set of x-rays is usually ordered to make sure that there are no broken bones in the knee. MRI’s are obtained primarily to assess the extent of the damage to other structures including the menisci, joint surfaces and bone.

Is there usually other damage to the knee when the ACL is torn?

Other ligaments in the knee can be injured at the same time as the ACL.  These may need to be repaired, but many times heal adequately without surgery.

The most common injury that occurs with the ACL tear is a meniscus tear.  Some meniscus tears can be repaired and some can be trimmed back so that the torn edges are smooth. If the meniscus can be repaired, it is usually done at the time of the ACL surgery.

Another common injury that can occur with an ACL tear is damage to the cartilage on the joint surface.  Damage to these surfaces is very serious and in some cases is the worst part of the injury.  It may require more complex surgery which is usually done at the time of the ACL surgery.

Does a torn ACL have to be fixed with surgery?

The ACL cannot heal on its own, but not all tears of the ACL need to be fixed.  This depends on age and your activity level.  People under 40 years of age should have their ACL reconstructed to prevent arthritis.  People participating in activities where they plant their feet and twist or cut are susceptible to having an unstable knee and may be better off with surgery.  People with strenuous jobs may also need surgery.  People who are unwilling or unable to modify their activities and desire an unrestricted lifestyle are encouraged to consider the surgery to have the best chance of returning to their previous lifestyle.  Advances in arthroscopic surgery and an aggressive rehabilitation program contribute to an accelerated recovery for patients with ACL injuries.

On the other hand, people who lead a more sedentary lifestyle may be able to get by with exercise and a brace.  However, even someone with a sedentary lifestyle may experience giving way with simple activities such as climbing or descending stairs or stepping off a curb.  In these cases surgery is needed to restore normal every day activities and to prevent further damage to the knee.

If I don’t have my ACL fixed am I likely to hurt my knee again or get arthritis?

Even if the knee joint does not become unstable (give way) it will still be loose after an ACL injury.  This leads to damage in other supporting structures, such as the medial and lateral collateral ligaments and the cushion pads called meniscus cartilages.  In someone with a recent ACL injury, the risk of associated meniscus damage may be 30 to 40 percent.  In someone who has had an ACL injury that has been present for years and who may have buckling episodes, the risk of associated meniscus damage is 90 percent. ACL and meniscus injury may contribute to the early onset of arthritis in your knee.

How is the ACL fixed?

The ACL is reconstructed with arthroscopic techniques.  The arthroscope is a fiber optic instrument (narrower than a pen), which is put into the joint through small incisions.  A camera is attached to the arthroscope and the image is viewed on a TV monitor.  The arthroscope allows Dr. Wilson to fully evaluate the entire knee joint.  Small instruments ranging from 3-9 millimeters in size are inserted through additional incisions so that he can feel the various joint structures, diagnose the injury, and then repair, reconstruct or remove the damaged structure.

As mentioned above, the ACL cannot heal on it’s own.  As a result, a new ligament must be inserted into the knee in it’s place; re-creating the function of the ACL.  In ACL reconstruction a replacement graft is precisely positioned in the joint at the site of the former ACL and then fixed to the thigh and lower leg bones with buttons, sutures or screws.  There are currently several options for replacement grafts.  Choices for the type of replacement graft include autograft (using your own tissue) and allograft (donor tissue).

Autografts can come from your patellar tendon, quadriceps tendon or the hamstring tendons.  The graft choice to be used is determined by you and Dr. Wilson.  All of these graft options offer a strong graft, secure fixation and excellent long-term results.  The results show that people are able to return to their activities with few complications.  Since the graft comes from your own body there is no chance of infectious disease transmission or rejection.

Allografts are donor tissues taken from tissue banks.  They also are strong grafts with excellent long-term results.  Because Dr. Wilson is not taking the tissue from your body, the surgical time and operative pain are less.  This allows for easier rehabilitation in the early post-operative stages. Although there is a risk of infectious disease, donor tissue is received only from a reliable tissue bank.  The tissue is rigorously screened and treated to prevent the spread of infectious disease.  The risk of contracting infectious disease from an allograft is very small (less than one in eight million).  Although rejection of the graft is possible, the risk of this is extremely low because the tissue is not living material.

Regardless of the graft material chosen, the most important aspect of surgery is that the ligament graft is placed and secured precisely.  Accurate graft placement is essential for a good result and secure graft placement permits early, more aggressive rehabilitation after surgery.  Dr. Wilson’s ACL reconstruction techniques are some of the most anatomically correct and minimally-invasive techniques available and have achieved outstanding results for countless of his patients.

What are some of the possible complications?

While complications are not common, all surgery has associated risks.  Possible complications include excessive stiffness after the surgery or pain in the knee or under the kneecap.  Your rehabilitation after surgery is specifically designed to address these issues.  Other complications can arise from infection of the wounds, phlebitis, bleeding into the knee, and nerve injury.

What do I need to do to prepare for surgery?

Our staff will work with you to set up the surgery through your insurance company and will instruct you in matters that you will need to take care of concerning your insurance paperwork.

Prior to surgery you may be asked to perform some exercises at home or with a physical therapist to prepare for surgery.  These exercises prepare the knee by decreasing the swelling, increasing the motion and maximizing the strength of your leg.

What type of anesthesia is used?

General anesthesia is used.  An anesthetist is always present if there is a need for further sedation or pain control.   The morning of surgery, an anesthetist will discuss with you the various options and answer your questions.

Because Dr. Wilson is extremely experienced, the operation can be performed rather quickly.  The shorter surgical time decreases the amount of anesthesia and limits side effects from the anesthesia.

How long will I be in the hospital?

The vast majority of people are able to have surgery and go home the same day. Occasionally, a night in the hospital is needed, although this is exceedingly rare.  How long you stay will depend on several factors including your age, health status, other damage in the knee, and the side effects of anesthesia.

What happens the day of surgery?

The day before surgery you will be told what time to report to the hospital the next day.  It is very important to arrive on time.  You will be admitted to the hospital and taken to a pre-operative area where you will be prepared for your surgery and then taken to the operating room.

Note:  You may not eat or drink anything after midnight the night before your surgery.  If you must take medicine then you will be permitted to do so with just a sip of water.

After the operation, you will be taken to the recovery room to be monitored.  Here the staff will check that the effects of the anesthesia are wearing off properly and they will provide you with medication for any pain you are having.  If you are going home the same day, you will be given specific instructions to follow at home and discharged after you have adequately recovered.  If you have to remain overnight, you will be taken to your room when you are ready.

How should I care for my knee after surgery?

Prior to your discharge from the hospital you will be given specific instructions on how to care for your knee.  It is important to follow these instructions.  If you have any questions, please don’t hesitate to give Dr. Wilson’s office a call at (334) 749-8303.