Anterior Cruciate Ligament (ACL) Reconstruction Guide

ACL tears are a common knee injury and often happen while playing sports.

Tears or ruptures of the ACL often happen as a result of:

• Poor landing after jumping (especially if the leg is straightened)
• Stopping suddenly
• Changing direction suddenly
• A blow to the knee (often from the front)

ACL reconstruction surgery is a good option for patients who are negatively impacted by the pain and mobility issues caused by their ACL tear. However, not every patient with an ACL tear needs surgery.

Surgery may be recommended to you if your ACL injury causes:

• Instability
• Difficulty moving
• Knee pain that is not well managed with painkillers or physiotherapy
• Risk of damage to other parts of the knee

Younger and generally healthy patients with no significant medical conditions make the best candidates for ACL reconstruction.

It is important that there is no swelling in the knee when a patient has ACL reconstruction surgery. Physiotherapy may help reduce swelling while also strengthening the muscles around the knee and improving the range of motion. Both of these factors can improve the outcome of surgery and reduce recovery times.

Patients with arthritis in their knee or a history of difficult-to-manage diabetes may not be suitable for this procedure.

The cost of ACL repair varies in price across the UK. Prices can range from £4500 to £7000 depending on many factors, such as:

The hospital location, the techniques used during surgery, preexisting health conditions, and the pre-and postoperative services included with surgery can all impact the cost of ACL reconstruction surgery.

• Surgeon experience
• Chosen hospital
• Anaesthetist expertise
• The complexity of the procedure for an individual's case, including pre-existing medical conditions
• Amount of hours required in surgery for each patient's case
• Pre- and postoperative services
• Surgical technique

In order to get a tailored price adapted to each personal case, patients will need to be examined by a surgeon in consultation to ensure that the procedure can be done considering their individual needs. A patient's personalised price will be all-inclusive and take into account all of the patient's needs; the tailored ACL reconstruction price will cover:

• Highly rated CQC hospital cost
• Surgeon's experience
• Anaesthetist time and expertise
• Any overnight stays that are required
• Follow-up appointments and aftercare

Even if a patient’s ACL is only torn and not completely detached, reconstructing the entire ligament is still the best treatment. This is because sutures or stitches to the ACL are overwhelmingly ineffective. Anterior cruciate ligament reconstruction surgery generally takes between one and two and a half hours.

While ACL reconstruction can be done with a traditional open incision down the front of the knee, arthroscopic methods are much less invasive and more popular currently. This overview only focuses on arthroscopic ACL reconstruction surgery.

Arthroscopic ACL repair surgery can be done under general anaesthesia, where the patient is given medication that puts them into a deep, dreamless sleep or a spinal block called an epidural. An epidural involves an injection into the spine that numbs the lower part of the body. Patients are often given a sedative along with the epidural so they feel relaxed during surgery.

ACL Reconstruction Incisions

Arthroscopic ACL reconstruction surgery requires small incisions for a camera with a light, cannula, and surgical tools to be inserted into the knee to perform the surgery. Another incision may be necessary at the location where the donor ligament will be taken (the back of the thigh or above or below the knee).

Types of Grafts for ACL Reconstruction

Each type of ACL graft has its own strengths and weaknesses. The surgeon will discuss with the patient what type of graft is best for their knee and their lifestyle.

Autograft

Autografts are taken from another location in the patient’s own body. This is the most common type of graft used for ACL reconstruction. As autografts produce a stronger resulting ligament, this method is well-suited for very active patients, including professional athletes.

The benefits of autografts include:

• Associated with a stronger ACL after recovery compared to donor grafts or synthetic implants
• Very little chance of graft rejection as it’s the patient’s own tissue
• More natural approach than other graft options

This approach to ACL reconstruction does, however, require a longer and more invasive surgery with more incisions than other techniques.

Autografts are most commonly taken from the:

• The patellar tendon located on the front of the knee
• The hamstring tendon on the inner side of the back of the knee
• Quadricep tendon above the knee

Patellar tendon grafts are considered the gold standard because of their low risk of rejection strength and come with the added benefit of easily including segments of bone on each end of the graft ligament that help connect it with the bones in the knee.

Allograft

Allografts are ligaments prepared from the patellar or Achilles tendons from deceased tissue donors.

While allografts are generally weaker than autografts, they are strong enough for many patients who do not live extremely active lives.

The benefits of allograft compared to other graft options are:

• A less invasive surgical procedure
• Shorter surgery time
• Suitable for multiple or extreme knee injuries

The disadvantages of allografts for ACL reconstruction surgery include:

• Limited availability of donor ligament tissue
• Slightly more expensive than other methods
• Higher risk of ligament rejection
• Higher graft failure risk
• Potentially longer recovery period

Synthetic Graft

Medical technology has produced synthetic grafts made of medical-grade polyester.

Synthetic grafts are most suitable for patients having revision ACL reconstruction or having multiple ligaments replaced at one time.

Disadvantages associated with synthetic grafts compared to other graft sources include:

• More difficult to adhere to the synthetic graft to the knee bones
• Results are slightly weaker than from autograft

Once the knee is cleaned and the incisions are made, the surgery can begin. First, incisions known as port sites are made on the knee to allow the arthroscopic tools to be inserted. The tools used can be seen in the diagram below. They include a camera and light as well as a cannula.

After the tools are inserted, the knee is filled with sterile water. This allows for the camera's better visibility and provides more room for the tools to manoeuvre.

• Once the knee is prepared, the surgeon examines the structures of the knee, including the damage to the ACL.
• They remove the damaged ACL completely (usually done with a shaver tool) to begin the reconstruction.
• The ACL graft is then prepared (either removed from the patient’s body or a donor ligament is cut to the exact length needed for reconstruction)
• Holes are then drilled into the femur and tibia (the bones above and below the knee, respectively).
• The ends of the graft are placed into these holes and can be secured with a screw or staple.
• Before ending the surgery, the surgeon will bend the knee to test the new graft for strength, stability and overall range of motion.
• When they are happy, the tools are removed, and the incisions are closed with sutures or another method, and the surgery is completed.

Many patients are able to return home the same day after their surgery; however, some may need to stay overnight in the hospital. A mobility aid like crutches may be needed to move around in the first few days after ACL reconstruction surgery. Patients are usually cautioned to bear their full weight on the knee in the week after surgery only if it is comfortable and does not cause any pain. The first few days will also call for rest, elevation, compression, ice and the potential use of a knee brace.

Physiotherapy is an important part of recovery after ACL repair. These appointments will begin one to two weeks after surgery and will continue for up to six months, depending on fitness level and recovery progress. Each patient has a physiotherapy plan unique to their needs; however, all programmes focus on:

• Building strength in the leg and knee
• Establishing a good range of movement in the knee as quickly as possible
• Keeping the patient active

Every surgery is associated with risks. These general surgical risks and complications include:

• Infection
• Blood clots or deep vein thrombosis
• Bruising
• Excessive bleeding

ACL repair surgery has other risks and complications specifically related to the procedure. These include:

• Lack of stability
• Patella/kneecap pain
• Patella inflammation (also called tendonitis)
• Knee stiffness
• Knee weakness
• Graft failure
• Further ACL injury
• Osteoarthritis

This varies on your abilities before the injury and the type of surgery you had, however typically, it will take at least 6 months to return to sports.

That will depend on the type of surgery and where the graft was taken from. For an open technique, the scar will run down the front of the knee and tibia, for an arthroscopic procedure, there will be multiple small incisions (about 1 cm) around the knee. There will be an additional scar if the graft was removed from somewhere on the leg other than the knee. Your surgeon will give you advice on how to minimise scarring.

You may need to take between 2 weeks and 3 months off work depending on your profession.

You will be advised to wear a protective cuffed plastic cover on your leg to help you shower until the wounds are fully healed. It may not be possible to use the bath until your wounds are fully healed unless you are able to keep your leg out of the water and at a safe and appropriate angle.

Some people are able to go home the same day, others may need to stay in hospital for at least a night.

As you will be unable to bear weight on your knee and will be using a mobility aid, like crutches, and potentially wearing a brace, taking care of pets and especially small children will be challenging as you recover. You will also not be able to drive for a portion of your recovery. Arranging for friends or family to help you care for your dependents will be necessary.

All of the information found on our website is sourced from highly reputable experts, government-approved authorities and is widely used by healthcare professionals.

• Uptodate.com Up to Date
• https://www.nhs.uk/conditions/knee-ligament-surgery/ NHS

Our content is written by our Medical Quality Managers and Patient Care Advisers, all of who have medical backgrounds and training. Prior to publishing, all the information is reviewed by a surgeon specialised within the relevant field.