If you require ACL Repair you can have full confidence in the service we provide:
- ACL Reconstruction Experts
- Dedicated Knee Only Practice
- More Than 20 Years Of Orthopaedic Surgery Experience
Contact us now! Appointments Available Within 48 Hours!
Anterior cruciate ligament reconstruction is the most common ligament reconstructive procedure with a 5 – 10% likelihood of the community rupturing their ACL at some point. Some patients are more at risk than others and most patients experience episodes of instability and giving way when changing direction after tearing their ACL. The surgery is done with keyhole technique and usually requires an overnight stay in hospital.
What is the Anterior Cruciate Ligament (ACL)?
The anterior cruciate ligament (ACL) is a cord of tissue in the middle of the knee connecting the femur and tibia and acts as a key stabiliser for rotation and change in direction activities. When it is torn, it allows the knee to move abnormally resulting in an unsteady knee which is 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 – intercondylar notch, body mass) and activity level.
Common Causes for ACL Injuries
At risk activities include any sport or activity that involves changing direction whilst trying to slow down or stop (netball, touch football, skiing) as this is the most common mechanism of rupturing your ACL. Other ways that an ACL may be injured is a blow to the outside of the knee with associated rupture of the medial collateral ligament (MCL) or a blow towards the front of the knee with a foot planted on the ground resulting in hyperextension such as in a football tackle or if landing awkwardly after a jump in the air (basketball or AFL). Repeated episodes of giving way over time puts the knee at risk for damage to the meniscal and articular cartilage with increased risk of developing arthritis.
How is an ACL Recontructed?
Reconstruction of the ACL is done using a predominantly key hole procedure with three small incisions, two of which are made in a horizontal orientation on the front of the knee and usually measuring less than 1cm each with the third incision being vertically oriented and positioned on the inner aspect of the lower part of the knee and usually measuring 3cms or less. The two horizontal incisions are used for the keyhole or arthroscopic visualisation and instrumentation of the knee and the vertical incision is used to harvest two small tendons from the medial thigh to reconstruct the ACL and to also drill the tibial bony tunnel for passage of the graft. Once the two tendons have been joined together and fashioned into an ACL like structure, it is firstly passed into the tibial drill hole and then into the knee joint before passing and securing in both the femur and tibia with small metallic devices (titanium RCI screw, endobutton). 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 positioning of the femoral and tibial tunnels and fixation devices. Patients usually will use crutches for comfort for the first week or two with most patients able to walk without crutches after two weeks unless a torn meniscus was also repaired with sutures, in which case crutches may be needed for up to 6 weeks. Patients commence a self directed exercise protocol with intermittent physiotherapy supervision to help regain their strength and range of motion and are usually able to recommence leg weights and gym work by 3 months, unidirectional running by 4 months, multidirectional drills by 5 months, sports drills by 6 months and return to sporting competition by the end of their 6th month of rehabilitation. Most patients are able to return to work duties within a week or two if office based and more slowly if performing heavy manual duties. Once completing your ACL rehabilitation, the likelihood of rupturing your reconstructed ACL is usually lower than the likelihood of injuring the ACL in your other knee and patients should be able to resume all sporting and outdoor activities with confidence.
ACL Reconstruction & Knee Arthritis Treatment
Occasionally patients will present with both an ACL deficiency and arthritis on the inner or medial compartment (most common) or the outer or lateral compartment (less common) and will require consideration of both an ACL reconstruction and a high tibial osteotomy (HTO) which can be performed in a staged manner, one after the other with the ACL reconstruction first and the HTO at least 3 months later. This can also be performed as a combined simultaneous procedure where both the ACL reconstruction and high tibial osteotomy are done 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 prior to proceeding to ACL reconstruction and suffered damage to the meniscus and articular cartilage either at the time of their ACL injury, or subsequent to that from repeated giving way episodes (see osteotomy, combined ACL reconstruction and osteotomy).
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. At the time a HTO is performed, if done using an opening wedge technique, the plate can be positioned (posteriorly, sloped forwards) such that it helps overcome the symptoms of arthritis, but also conveys some benefit to the instability symptoms of an ACL deficient knee with alteration of the tibial downslope (see Osteotomy). The position of the incision for the harvesting of the hamstring graft used for ACL reconstruction and the incision used for the HTO are closely located with the position of the tibial plate for the HTO often positioned partially or totally over where the tibial tunnel for the ACL reconstruction would be drilled.
Rehabilitation after ACL Reconstruction & HTO
As such, 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 and usually adds 2 months to the overall rehabilitation period that would be followed for an ACL reconstruction in isolation with leg weights at 5 months, straight line jogging at 6 to 7 months, multidirectional running at 7 to 8 months and sport at 8 to 9 months.
Return to the sport and activities you love. Organise a consultation today and get fast, expert advice on the best options for you!