- History of Injury
- Indications for surgery
- Risks & Complications
Find out more about ACL Reconstruction Hamstring Tendon with the following link
Find out more about ACL Reconstruction Patellar Tendon with the following link
The anterior cruciate ligament is one of the major stabilizing ligaments in the knee. It is a strong ‘rope-like’ structure located in the centre of the knee attaching the femur (thighbone) to the tibia (shinbone).
When this stabilising ligament tears, it unfortunately fails to heal anatomically and often leads to instability of the knee joint.
ACL reconstruction to restore stability is a commonly performed surgical procedure and with recent advances in arthroscopic surgery can now be performed with minimally invasive incisions and low complication rates.
The ACL is one of the major stabilizing ligaments in the knee. It prevents the tibia (shin-bone) moving abnormally underneath the femur (thigh-bone). When this abnormal movement occurs it causes instability and the patient may well be aware of this abnormal movement as the knee may collapse.
Often other structures, such as the meniscal cartilage (shock absorber), the articular cartilage (lining of the joint) or other ligaments may be damaged alongside an ACL injury and these may need to be addressed at the time of surgery.
- Most injuries are sports related involving a twisting injury to the knee
- It can occurs with a sudden change of direction, a direct blow e.g., a tackle or landing awkwardly from a jump
- Often there is a ‘popping’ sound when the ligament ruptures
- Swelling usually occurs shortly after the injury
- There is often the feeling of the knee collapsing or ‘slipping’ out of joint
- It is rare to be able to continue playing sport after the initial injury
Once the initial injury settles down, the main symptom is instability or ‘giving-way’ of the knee. This usually occurs with twisting activities but can occur on simple walking or other activities of daily living.
The diagnosis can often be made on the history alone.
Examination reveals instability of the knee, if adequately relaxed and not too painful.
An MRI (Magnetic Resonance Imaging) can be helpful if there is doubt as well as to look for damage to other structures within the knee.
More rarely, the final diagnosis can only be made after an examination under anaesthetic or with an arthroscopy.
Some people can compensate for the injured ligament with strengthening exercises or a brace and may be able to avoid the need for reconstruction. If the knee remains unstable, the evidence from scientific literature is that there is an ongoing and cumulative risk of further damage to the rest of the joint.
It is strongly advised to give up sports involving twisting activities, if you have an ACL injury.
- Episodes of instability can cause further damage to important structures within the knee that may result in early arthritis
Young patients wishing to maintain an active lifestyle.
Sports involving twisting activities e.g., Football, rugby, netball, Giving way with activities of daily living.
People with dangerous occupations e.g., Policemen, firemen, roofers, scaffolders.
It is advisable to have physiotherapy prior to surgery to regain motion and strengthen the muscles as much as possible.
Surgical techniques have improved significantly over the last decade, complications are reduced and recovery much quicker than in the past.
The surgery is performed arthroscopically. The ruptured ligament is removed and then tunnels (holes) in the bone are drilled to accept the ACL graft. This graft which replaces the patient’s old ligament may be taken either from the hamstring tendon, the patella tendon or the quadriceps tendon. There are advantages & disadvantages of each, with the final decision based on the most appropriate graft choice for you.
The graft is prepared to take the form of a new tendon and passed through the drill holes in the bone.
The new tendon is then fixed into the bone with mechanical devices to hold it in place while the ligament heals into the bone (usually 3-6 months).
The rest of the knee can be clearly visualized at the time of surgery and any other damage is dealt with e.g., meniscal tears.
The wound is then closed and a dressing is applied.
Surgery is performed as a day-case procedure or an overnight stay.
You will have pain medication by tablet or in a drip (intravenous). Your anaesthetist may suggest a nerve ‘block’.
Any drains will be removed from the knee.
A splint is sometimes used for comfort or to protect the knee
You will be seen by a physiotherapist who will teach you to use crutches and show you some simple exercises to do at home.
Leave any waterproof dressings on your knee until your post-op review.
You can put all your weight on your leg.
Avoid anti-inflammatories or aspirin for 10 days.
Put ice on the knee (through a cloth) for 20 minutes at a time, as frequently as possible.
Your first post-op review will usually be at 12-14 days.
Physiotherapy can begin after a few days or can be arranged at your first post-op visit.
If you have any redness around the wound or increasing pain in the knee, if you have a temperature or feel unwell, you should contact your doctor as soon as possible.
Physiotherapy is an integral part of the treatment and it is recommended that this starts as early as possible. Preoperative physiotherapy is helpful to better prepare the knee for surgery. The early aim is to regain range of motion, reduce swelling and achieve full weight bearing.
The remaining rehabilitation will be supervised by a physiotherapist and will involve activities such as exercise bike riding, swimming, proprioceptive (neuromuscular) exercises and muscle strengthening. Static cycling can begin at 6 weeks, jogging can generally begin at around 3 months. The graft is strong enough to allow sport at around 6 months however other factors come into play such as confidence, fitness and adequate strength, fitness and training.
Professional sportsmen/women often return at 6 months but recreational athletes may take 10 -12 months depending on motivation and time put into rehabilitation.
The rehabilitation and overall success of the procedure can be affected by associated injuries to the knee such as damage to the meniscus, articular cartilage or other ligaments of the knee.
The following is a more detailed hamstring ACL rehabilitation protocol useful for patients and physiotherapists. It is a guide only and must be adjusted on an individual basis taking into account pain, other pathology, work and other social factors.
Acute (0 – 2 Weeks)
- Wound healing
- Reduce swelling
- Regain full extension
- Full weight bearing
- Wean off crutches
- Promote muscle control
- Pain and swelling reduction with ice, intermittent pressure pump, soft tissue massage and exercise
- Patella mobilisation
- Active range of motion knee exercises, calf and hamstring stretching, contraction (non weight bearing progressing to standing), muscle control and full weight bearing. Aim for full extension by 2 weeks. Full flexion will take longer and generally will come with gradual stretching. Care needs to be taken with hamstring co contraction as this may result in hamstring strains if too vigorous. Light hamstring loading continues into the next stage with progression of general rehabilitation. Resisted hamstring loading should be avoided for approximately 6 weeks
- Gait retraining encouraging extension at heel strike
Stage 2- Quadriceps Control (2-6 Weeks)
- Full active range of motion
- Normal gait with reasonable weight tolerance
- Minimal pain and effusion
- Develop muscular control for controlled pain free single leg lunge
- Avoid hamstring strain
- Develop early proprioceptive awareness
- Use active, passive and hands on techniques to promote full range of motion
- Progress closed chain exercises (quarter squats and single leg lunge) as pain allows. The emphasis is on pain free loading, VMO and gluteal activation
- Introduce gym based exercise equipment including leg press and stationary cycle
- Water based exercises can begin once the wound has healed, including treading water, gentle swimming avoiding breaststroke
- Begin proprioceptive exercises including single standing leg balance on the ground and mini tramp. This can progress by introducing body movement whilst standing on one leg
- Bilateral and single calf raises and stretching
- Avoid isolated loading of the hamstrings due to ease of tear. Hamstrings will be progressively loaded through closed chain and gym based activity
Stage 3- Hamstring/Quadriceps Strengthening (6-12 Weeks)
- Begin specific hamstring loading
- Increase total leg strength
- Promote good quadriceps control in lunge and hopping activity in preparation for running
- Focal hamstring loading begins and is progressed steadily throughout the next stages of rehabilitation
- Active prone knee flexion which can be quickly progressed to include a light weight and gradually increasing weights
- Bilateral bridging off a chair. This can be progressed by moving onto a single leg bridge and then single leg bridge with weight held across the abdomen
- Single straight leg dead lift initially active with increasing difficulty by adding dumbbellsWith respect to hamstring loading, they should never be pushed into pain and should be carefully progressed. Any subtle strain or tightness following exercises should be managed with a reduction in hamstring based exercises
- Gym based activity including leg presses, light squats and stationary bike which can be progressively increased in intensity as pain and control allow. It is important to monitor any effusions following exercise and if it is increasing then exercise should be toned down
- Once single leg lunge control is comparable to the other side hopping can be introduced. Hops can be made more difficult by including variations such as forward/back, side to side off a step and in a quadrant
- Running may begin towards the latter part of this stagePrior to running certain criteria must be met
- No anterior knee pain
- A pain free lunge and hop that is comparable to the other side
- The knee must have no effusion
- Before jogging start having brisk walks, ideally on a treadmill to monitor landing
- Action and any effusion. This should be done for several weeks before jogging properly
- Increased proprioceptive manoeuvres with standing leg balance and progressive hopping based activity
- Expand calf routine to include eccentric loading
Stage Four-Sport Specific (3-6 Months)
- Improve leg strength
- Develop running endurance speed, change of direction
- Advanced proprioception
- Prepare for return to sport and recreational lifestyle
- Controlled sport specific activities should be included in the progression of running and gym loads. Increasing effusion post running that isn’t easily managed with ice should result in a reduction in running loads
- Advanced proprioception to include controlled hopping and turning and balance correction
- Monitor potential problems associated with increasing loads
- No open chain resisted leg extension exercises unless authorised by your surgeon
Stage Five-Return to Sport (6 Months Plus)
A safe return to sporting activities
- Full training for 1 month prior to active return to competitive sport
- Preparation for body contact sports. Begin with low intensity one on one contests and progress by increasing intensity and complexity in preparation for drills that one might be expected to do at training
- To improve running endurance leading up to a normal training session
- Full range, no effusion, good quadriceps control for lunge, hopping and hop and turn type activity. Circumference measures of thigh and calf to within 1 cm of other side
Complications are not common but can occur. Prior to making the decision to have this operation, it is important that you understand these so that you can make an informed decision regarding the advantages and disadvantages of surgery.
These can be Medical (Anaesthetic) complications and surgical complications
Medical (Anaesthetic) complications
Medical complications include those of the anaesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include
Allergic reactions to medications
Blood loss (potentially requiring transfusion with its low risk of disease transmission), heart attacks, strokes, kidney failure, pneumonia, bladder infections/urinary retention. Complications from nerve blocks such as infection, pain or nerve damage resulting in numbness and weakness. Serious medical problems can lead to ongoing health concerns and prolonged hospitalization.
The following is a list of surgical complications. These are all rare but can occur. Most are treatable and do not lead to long term problems.
Approximately 1 in 200. Treatment involves either oral or antibiotics through a drip, or rarely, further surgery to wash the infection out.
Deep vein thrombosis
These are clots in the veins of the leg. If they occur you may need blood thinning medication in the form of injections or tablets. Very rarely, they can travel to the lung (Pulmonary Embolism) which can cause breathing difficulties or even death.
Excessive swelling & Bruising
This can be due to bleeding in the soft tissues and will settle with time.
Can result from scar tissue within the joint, and is minimized by advances in surgical technique and rapid rehabilitation. Full range of movements cannot always be guaranteed.
The graft can fail in the same way as a normal cruciate ligament can. Failure rate is approximately 5%. If the graft stretches or ruptures it can still be revised if required using alternative graft material (sometimes from the other leg).
Damage to nerves or vessels
These are small nerves under the skin which cannot be avoided and cutting them can lead to an area of numbness in the leg. This normally reduces in size over time and does not cause any functional problems with the knee. Very rarely there can be damage to more important nerves or vessels causing weakness/numbness in the leg.
All grafts need to be fixed to the bone using various devices (hardware) such as screws or staples. These can cause irritation of the wound and may require removal when the graft has grown into the bone.
Donor site problems
‘Donor site’ means where the graft is taken from. In general either the hamstrings or patella tendon are used. These can include pain or swelling in these areas which usually resolves over time. A subtle loss of function is not usually noticed.
Can occur especially if there is damage to other structures inside the knee
Complex Regional Pain Syndrome
An extremely rare condition that is not entirely understood, which can cause unexplained and excessive pain.
Anterior Cruciate Ligament reconstruction is a common and very successful procedure. If your surgery is carried out by experienced knee surgeons, such as those at ‘The Cambridge Knee’, who perform a lot of these procedures, 95% of people have a successful result. It is generally recommended in a patient wishing to return to an active lifestyle especially those wishing to play sports involving running and twisting.
The above information has hopefully educated you on the choices available to you, the procedure and the risks involved. If you have any further questions you should consult with your surgeon.